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Emeli IM, Abiri A, Hughes G, Moran TP, Keadey MT, Ross MA. The benefits of a virtual emergency department observation unit for hospital observation patients. Am J Emerg Med 2024; 84:59-67. [PMID: 39094242 DOI: 10.1016/j.ajem.2024.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 07/16/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The benefit of virtual emergency department observation unit (EDOU) care relative to traditional observation care in an inpatient bed is unknown. OBJECTIVE To determine if virtual observation care in an EDOU is associated with improved length of stay, cost, inpatient admission rate, and adverse events relative to traditional observation care in non-observation unit (NOU) inpatient bed. METHODS This is a retrospective observational cohort study of observation patients managed over 24 months in two urban teaching hospitals. Following an ED visit, observation care occurred in a virtual-EDOU or NOU inpatient setting based on bed availability, physician discretion, and observation guidelines. Primary outcomes were length of stay, total cost, inpatient admission rate, and adverse events (death or ICU admission). Hospital cost and clinical databases were used. Analysis with a doubly-robust regression with entropy balancing and propensity scores was used to control for subgroup differences. RESULTS 30,191 observation patients were divided into 13,753 NOU patients and 16,438 EDOU patients with similar distributions for age and gender, and differences in health insurance and diagnosis. For both discharged and admitted patients, the mean cost was higher in the NOU setting at $7989 than the virtual-EDOU setting at $4876 with an adjusted difference of $1951 (95% CI: $1762-$2133). The mean total length of stay was higher in the NOU setting (60.5 h) than the virtual-EDOU setting (36.4 h) with an adjusted difference of 20.4 h (95% CI: 19.2 h - 21.3 h). NOU inpatient admission rates were higher (25.3% vs 18.4%). Cost and length of stays were lower in discharged observation patients, with differences favoring the virtual-EDOU group. Adverse events were higher in the NOU setting (2.1% vs 0.8%). 30-day ED recidivism did not differ significantly between NOU and virtual-EDOU study groups. The virtual-EDOU saved the two hospitals $16,036,913 and 6986 bed-days annually. CONCLUSION Management of observation patients in a virtual-EDOU setting is superior to care in a traditional inpatient setting in terms of costs, length of stays, inpatient admission and adverse events rates.
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Affiliation(s)
- Iyesatta M Emeli
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Autherine Abiri
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA; Neil Hodgson Woodruff School of Nursing, Emory University, USA
| | - George Hughes
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew T Keadey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael A Ross
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Burgese R, Wasef B, Wang D. An efficient approach to the inpatient Syncope Workup. Postgrad Med 2024. [PMID: 39292489 DOI: 10.1080/00325481.2024.2406742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 09/06/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE This review aims to provide hospitalists with a streamlined understanding of the evaluation of syncope, a commonly encountered complaint in hospital medicine. METHODS Authors conducted a literature review using the keyword 'syncope' to compile current evidence and recommendations regarding the categorization, risk stratification, and diagnostic evaluation of syncope. RESULTS The review outlines the categorization of syncope into cardiac, neurally-mediated, and orthostatic types, detailing the clinical features, etiologies, and differential diagnoses of each. It provides a structured framework for history-taking, physical examination, orthostatic vital sign assessment, and risk stratification to guide clinicians in efficiently identifying high-risk patients requiring urgent intervention. Diagnostic modalities including electrocardiography, echocardiography, and point-of-care ultrasound are discussed, along with their respective indications and limitations. CONCLUSION By embracing standardized approaches and evidence-based practices outlined in this review, hospitalists can optimize resource utilization, streamline patient care, and improve outcomes in patients presenting with syncope.
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Affiliation(s)
| | - Beman Wasef
- Internal Medicine, Lankenau Medical Center, PA, USA
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Furlan L, Jacobitti Esposito G, Gianni F, Solbiati M, Mancusi C, Costantino G. Syncope in the Emergency Department: A Practical Approach. J Clin Med 2024; 13:3231. [PMID: 38892942 PMCID: PMC11172976 DOI: 10.3390/jcm13113231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Internal Medicine Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giulia Jacobitti Esposito
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Francesca Gianni
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Monica Solbiati
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Costantino Mancusi
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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4
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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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Candelli M, Lumare M, Riccioni ME, Mestice A, Ojetti V, Pignataro G, Merra G, Piccioni A, Gabrielli M, Gasbarrini A, Franceschi F. Are Short-Stay Units Safe and Effective in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1021. [PMID: 37374225 DOI: 10.3390/medicina59061021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/05/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Introduction: Emergency Department (ED) overcrowding is a health, political, and economic problem of concern worldwide. The causes of overcrowding are an aging population, an increase in chronic diseases, a lack of access to primary care, and a lack of resources in communities. Overcrowding has been associated with an increased risk of mortality. The establishment of a Short Stay Unit (SSU) for conditions that cannot be treated at home but require treatment and hospitalization for up to 72 h may be a solution. SSU can significantly reduce hospital length of stay (LOS) for certain conditions but does not appear to be useful for other diseases. Currently, there are no studies addressing the efficacy of SSU in the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Our study aims to evaluate the efficacy of SSU in reducing the need for hospitalization, LOS, hospital readmission, and mortality in patients with NVUGIB compared with admission to the regular ward. Materials and Methods: This was a retrospective, single-center observational study. Medical records of patients presenting with NVUGIB to ED between 1 April 2021, and 30 September 2022, were analyzed. We included patients aged >18 years who presented to ED with acute upper gastrointestinal tract blood loss. The test population was divided into two groups: Patients admitted to a normal inpatient ward (control) and patients treated at SSU (intervention). Clinical and medical history data were collected for both groups. The hospital LOS was the primary outcome. Secondary outcomes were time to endoscopy, number of blood units transfused, readmission to the hospital at 30 days, and in-hospital mortality. Results: The analysis included 120 patients with a mean age of 70 years, 54% of whom were men. Sixty patients were admitted to SSU. Patients admitted to the medical ward had a higher mean age. The Glasgow-Blatchford score, used to assess bleeding risk, mortality, and hospital readmission were similar in the study groups. Multivariate analysis after adjustment for confounders found that the only factor independently associated with shorter LOS was admission to SSU (p < 0.0001). Admission to SSU was also independently and significantly associated with a shorter time to endoscopy (p < 0.001). The only other factor associated with a shorter time to EGDS was creatinine level (p = 0.05), while home treatment with PPI was associated with a longer time to endoscopy. LOS, time to endoscopy, number of patients requiring transfusion, and number of units of blood transfused were significantly lower in patients admitted to SSU than in the control group. Conclusions: The results of the study show that treatment of NVUGIB in SSU can significantly reduce the time required for endoscopy, the hospital LOS, and the number of transfused blood units without increasing mortality and hospital readmission. Treatment of NVUGIB at SSU may therefore help to reduce ED overcrowding but multicenter randomized controlled trials are needed to confirm these data.
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Affiliation(s)
- Marcello Candelli
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Maria Lumare
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Maria Elena Riccioni
- Medical and Abdominal Surgery and Endocrine-Metabolic Scienze, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Antonio Mestice
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Veronica Ojetti
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Giulia Pignataro
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Giuseppe Merra
- Biomedicine and Prevention Department, Section of Clinical Nutrition and Nutrigenomics, Facoltà di Medicina e Chirurgia, Università degli Studi di Roma Tor Vergata, 00133 Rome, Italy
| | - Andrea Piccioni
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Maurizio Gabrielli
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Medical and Abdominal Surgery and Endocrine-Metabolic Scienze, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency, Anesthesiological and Reanimation Sciencese Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS of Rome, 00168 Rome, Italy
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Kavi KS, Gall NP. Trauma and syncope: looking beyond the injury. Trauma Surg Acute Care Open 2023; 8:e001036. [PMID: 36744295 PMCID: PMC9896213 DOI: 10.1136/tsaco-2022-001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
Background 42% of the population experience syncope by the age of 70, accounting for up to 6% of hospital admissions that frequently present as falls. The etiologies of some falls are benign, and others, such as cardiac syncope, are associated with a greater mortality and must be identified. Methods This review article aims to bridge the literature gap by providing a comprehensive practice review and critical summary of the current syncope guidance relating to the trauma patient. Results The National Institute for Health and Care Excellence, the American College of Cardiology, and European Society of Cardiology published syncope risk stratification guidance. The inclusion of certain high-risk features represented in all three guidelines suggests their significance to identify cardiac syncope including heart failure, abnormal vital signs, syncope during exercise with little to no prodrome, family history of sudden cardiac death, and ECG abnormalities. Of 11 syncope risk stratification scoring systems based on these guidelines, only 2 are externally validated in the emergency department, neither of which are validated for major trauma use. Adherence to thorough history-taking, examination, orthostatic blood pressure recording, and an ECG can diagnose the cause of syncope in up to 50% of patients. ECG findings are 95% to 98% sensitive in the detection of serious adverse outcomes after cardiac syncope and should form part of a standardized syncope trauma assessment. Routine blood testing in trauma is often performed despite evidence that it is neither useful nor cost effective, where the screening of cardiac enzymes and D-dimer rarely influences management. Discussion In the absence of a gold-standard clinical test to identify the cause of a syncopal episode, standardized syncope guidelines as described in this review could be incorporated into trauma protocols to analyze high-risk etiologies, improve diagnostic accuracy, reduce unnecessary investigations, and develop an effective and safer management strategy.
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Affiliation(s)
- Kieran S Kavi
- Department of Emergency Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicholas P Gall
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Emergency medicine (EM) can safely manage geriatric trauma patients sustaining ground level falls: Fostering EM autonomy while safely offloading a busy trauma service. Am J Surg 2022; 224:1314-1318. [DOI: 10.1016/j.amjsurg.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/26/2022] [Accepted: 07/20/2022] [Indexed: 11/23/2022]
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Sutton R, Ricci F, Fedorowski A. Risk stratification of syncope: Current syncope guidelines and beyond. Auton Neurosci 2022; 238:102929. [PMID: 34968831 DOI: 10.1016/j.autneu.2021.102929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Dept. of Cardiology, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via Luigi Polacchi, 11, 66100 Chieti, Italy; Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Artur Fedorowski
- Dept. of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden.
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Shabbir MA, Saad Shaukat MH, Ehtesham M, Murawski S, Singh S, Alimohammad R. Bifascicular block in unexplained syncope is underrecognized and under-evaluated: A single-center audit of ESC guidelines adherence. PLoS One 2022; 17:e0263727. [PMID: 35226666 PMCID: PMC8884493 DOI: 10.1371/journal.pone.0263727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/25/2022] [Indexed: 12/04/2022] Open
Abstract
Background The presence of bifascicular block on electrocardiography suggests that otherwise-unexplained syncope may be due to complete heart block. European Society of Cardiology (ESC) recommends investigating it with electrophysiology study (EPS). PPM is indicated if high-degree atrioventricular block is inducible. Long term rhythm monitoring with implantable loop recorder (ILR) is recommended if EPS is negative. We evaluated adherence to these guidelines. Methods This is a single-center retrospective audit of adult patients with bifascicular block hospitalized for unexplained syncope between January 2018 and August 2019 under general medicine service. Patients with an alternative explanation for syncope were excluded. Guideline adherence was assessed by formal cardiology consult and whether EPS followed by ILR and/or PPM were offered. Results 65 out of 580 adult patients (11.2%) admitted to general medicine service for syncope had a bifascicular block; 29 (5%) were identified to have bifascicular block and unexplained syncope. Median age was 77 ±10 years; 9 (31%) were female, and 6 (20.7%) patients had at least one prior hospital visit for syncope at our academic medical center. Cardiology was consulted on 17 (58.6%) patients. Two patients were evaluated by EPS (1 refused) followed by ILR. Overall, 3 out of 29 patients (10.3%) received guideline-directed evaluation during the hospitalization based on ESC guidelines. None of the patients received empiric PPM during the index hospitalization. Conclusion Among patients admitted to the general medicine service with unexplained syncope and bifascicular block, a minority (10.3%) underwent guideline-directed evaluation per ESC recommendations. Cardiology was consulted in 58.6% of cases.
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Affiliation(s)
- Muhammad Asim Shabbir
- Department of Internal Medicine, Albany Medical College, Albany, NY, United States of America
- * E-mail:
| | | | - Moiz Ehtesham
- Department of Internal Medicine, Albany Medical College, Albany, NY, United States of America
| | - Shannon Murawski
- Department of Internal Medicine, Albany Medical College, Albany, NY, United States of America
| | - Sukhraj Singh
- Department of Internal Medicine, Albany Medical College, Albany, NY, United States of America
| | - Rizwan Alimohammad
- Department of Cardiology, Capital Cardiology Associates, Albany Medical College, Albany, NY, United States of America
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Firouzbakht T, Shen ML, Groppelli A, Brignole M, Shen WK. Step-by-step guide to creating the best syncope units: From combined United States and European experiences. Auton Neurosci 2022; 239:102950. [DOI: 10.1016/j.autneu.2022.102950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
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Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
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Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111235. [PMID: 34833453 PMCID: PMC8623370 DOI: 10.3390/medicina57111235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/04/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.
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Terry N, Franks N, Moran T, Pitts S, Osborne A, Ross MA. The Changing Role of Chest Pain in the Emergency Department Observation Unit. Crit Pathw Cardiol 2021; 20:119-125. [PMID: 33534505 DOI: 10.1097/hpc.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study objective was to describe changes in the utilization of a protocol-driven emergency department observation unit (EDOU) for chest pain over time. METHODS This is a retrospective serial cross-sectional study of data from a clinical data warehouse of a single integrated healthcare system. We estimated long-term trends (2009-2019) in EDOU visits at 4 system hospitals, using monthly proportions as the main outcome, and month of visit as the exposure variable, accounting for age and sex. Rate changes associated with compulsory use of the History, EKG, Age, Risk factors, Troponin (HEART) score in 2016 were analyzed. RESULTS There were 83,168 EDOU admissions among 1.3 million ED visits during the study interval, with an average admission rate of 5.9% of ED visits. The most common conditions were chest pain (41.2%), transient ischemic attack (7.8%), dehydration (6.3%), syncope (5.8%), and abdominal pain (5.2%). In each hospital, there was a temporal annual decline in the proportion of EDOU visits for chest pain protocols ranging from -7.9% to -2.8%, an average rate of -3.3% per year (95% CI, -4.6% to -2.0%) or a 54% (from 54% to 25%) relative decline in over the 11-year study interval. This decline was significantly steeper in younger middle-aged patients (ages 39-49). The HEART score intervention had a small impact on baseline decline of -3.1% at the 2 intervention hospitals, reducing it by -1.5% (95% CI, -2.2% to -0.8%). CONCLUSIONS Utilization of the EDOU for chest pain decreased over time, with corresponding increases in other conditions. This decline preceded the introduction of the HEART score.
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Affiliation(s)
- Nataisia Terry
- From the Department of Emergency Medicine, Emory, Atlanta, GA
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Abstract
ABSTRACT Syncope is a common medical presentation that can cost the US healthcare system up to $2.4 billion dollars annually. Much of this cost can be mitigated with proper evaluation and management in the urgent care setting, as well as appropriate use of a risk stratification system.
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Affiliation(s)
- Brandon Geer
- Brandon Geer is an urgent care NP at United Memorial Medical Center Urgent Care, Batavia, N.Y
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Wheatley M, Kapil S, Lewis A, O’Sullivan J, Armentrout J, Moran T, Osborne A, Moore B, Morse B, Rhee P, Ahmad F, Atallah H. Management of Minor Traumatic Brain Injury in an ED Observation Unit. West J Emerg Med 2021; 22:943-950. [PMID: 35354002 PMCID: PMC8328171 DOI: 10.5811/westjem.2021.4.50442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress. Methods This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. Results There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. Conclusion Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.
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Affiliation(s)
- Matthew Wheatley
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Shikha Kapil
- Georgetown University School of Medicine, Department of Emergency Medicine, Washington, District of Columbia
| | - Amanda Lewis
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Jessica O’Sullivan
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Joshua Armentrout
- Atlanta Medical Center, Department of Emergency Medicine, Atlanta, Georgia
| | - Tim Moran
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Anwar Osborne
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Brooks Moore
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Bryan Morse
- Maine Medical Center, Department of Surgery and Surgical Critical Care, Portland, Maine
| | - Peter Rhee
- Westchester Medical Center, Department of Surgery, Trauma Surgery, and Surgical Critical Care, Valhalla, New York
| | - Faiz Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, Georgia
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Perry M, Franks N, Pitts SR, Moran TP, Osborne A, Peterson D, Ross MA. The impact of emergency department observation units on a health system. Am J Emerg Med 2021; 48:231-237. [PMID: 33991972 DOI: 10.1016/j.ajem.2021.04.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Protocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units. OBJECTIVE To determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization. METHODS A retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the "admit to observation" order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions. RESULTS The sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7-15.3) vs 26.4% (CI 21.3-32.3)], LoS differences [11.1 h (CI 10.6-11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year. CONCLUSION Within an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.
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Affiliation(s)
- Michael Perry
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole Franks
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen R Pitts
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Anwar Osborne
- Department of Emergency Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Michael A Ross
- Department of Emergency Medicine, Observation Medicine, Emory University School of Medicine, 531 Asbury Circle - Annex, Suite N340, Atlanta, Georgia.
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Dipaola F, Shiffer D, Gatti M, Menè R, Solbiati M, Furlan R. Machine Learning and Syncope Management in the ED: The Future Is Coming. ACTA ACUST UNITED AC 2021; 57:medicina57040351. [PMID: 33917508 PMCID: PMC8067452 DOI: 10.3390/medicina57040351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022]
Abstract
In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main applications in the emergency department (ED) setting, with a particular focus on syncope management. Through an extensive literature search in PubMed and Embase, we found increasing evidence suggesting that the use of ML algorithms can improve ED triage, diagnosis, and risk stratification of many diseases. However, the lacks of external validation and reliable diagnostic standards currently limit their implementation in clinical practice. Syncope represents a challenging problem for the emergency physician both because its diagnosis is not supported by specific tests and the available prognostic tools proved to be inefficient. ML algorithms have the potential to overcome these limitations and, in the future, they could support the clinician in managing syncope patients more efficiently. However, at present only few studies have addressed this issue, albeit with encouraging results.
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Affiliation(s)
- Franca Dipaola
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-0282247266
| | - Dana Shiffer
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
| | - Mauro Gatti
- IBM, Active Intelligence Center, 40121 Bologna, Italy;
| | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
| | - Monica Solbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Rozzano, 20089 Milan, Italy
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Adlan AM, Eftekhari H, Paul G, Hayat S, Osman F. The Impact of a Nurse-Led Syncope Clinic: Experience from a single UK tertiary center. J Arrhythm 2020; 36:854-862. [PMID: 33024463 PMCID: PMC7532277 DOI: 10.1002/joa3.12420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/30/2020] [Accepted: 08/06/2020] [Indexed: 12/02/2022] Open
Abstract
Background Syncope is a leading cause of hospital admission and is associated with significant morbidity and mortality. Our Syncope Clinic commenced in 2014 and we sought to evaluate its impact on outcomes (1‐yr mortality and syncope re‐hospitalization) in patients discharged following syncope admission. Methods A single‐center study of all consecutive patients discharged with syncope (ICD‐10 R55) between April 2012 and 2017. Patient demographics, comorbidities, hospital stay, syncope re‐hospitalization, and mortality at one‐year were collected. Those subsequently referred and seen in Syncope Clinic were compared with those who were not and predictors of poor outcome were evaluated. Results In total 2950 patients were discharged from hospital with syncope (median age: 73years, 51% male) with 1220 (41%) discharged same‐day; after commencement of Syncope Clinic 231were subsequently reviewed here. Overall mortality was 11%, which was lower in the Syncope Clinic group (3% vs 12%, P < .001). Temporal analysis revealed reduced re‐hospitalization following commencement of Syncope Clinic (2% vs 6%, P = .027). Independent predictors of mortality were increasing age (HR 1.03, 95% CI 1.03‐1.04), AF (HR 1.6, 95% CI 1.2‐2.1), HF (HR 2.2, 95% CI 1.6‐3.0), COPD (HR 1.9, 95% CI 1.4‐2.7), and CHADS2 score ≥ 1 (HR 1.45, 95% CI 1,12‐1.87). Syncope Clinic attendance was associated with reduced mortality (HR 0.3, 95% CI 0.1‐0.6). Conclusions Syncope patients discharged from hospital had reduced 1yr mortality if seen in subsequent Syncope Clinic. Independent predictors of mortality were COPD, HF, AF, and CHADS2 ≥1. Prospective randomized trials of Syncope Clinics are warranted.
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Affiliation(s)
- Ahmed M Adlan
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Helen Eftekhari
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Geeta Paul
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK
| | - Sajad Hayat
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK.,Department of Adult Cardiology Heart Hospital Hamad Medical Corporation Doha Qatar
| | - Faizel Osman
- Department of Cardiology University Hospitals Coventry & Warwickshire NHS Trust Coventry UK.,University of Warwick (Medical School) Coventry UK
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Sandhu RK, Raj SR, Thiruganasambandamoorthy V, Kaul P, Morillo CA, Krahn AD, Guzman JC, Sheldon RS, Banijamali HS, MacIntyre C, Manlucu J, Seifer C, Sivilotti M. Canadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope. Can J Cardiol 2020; 36:1167-1177. [PMID: 32624296 DOI: 10.1016/j.cjca.2019.12.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 10/23/2022] Open
Abstract
Syncope is a symptom that occurs in multiple settings and has a variety of underlying causes, ranging from benign to life threatening. Determining the underlying diagnosis and prognosis can be challenging and often results in an unstructured approach to evaluation, which is ineffective and costly. In this first ever document, the Canadian Cardiovascular Society (CCS) provides a clinical practice update on the assessment and management of syncope. It highlights similarities and differences between the 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society and the 2018 European Society of Cardiology guidelines, draws on new data following a thorough review of medical literature, and takes the best available evidence and clinical experience to provide clinical practice tips. Where appropriate, a focus on a Canadian perspective is emphasized in order to illuminate larger international issues. This document represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific advice. The primary writing panel wrote the document, followed by peer review from the secondary writing panel. The CCS Guidelines Committee reviewed and approved the statement. The practice tips represent the consensus opinion of the primary writing panel authors, endorsed by the CCS. The CCS clinical practice update on the assessment and management of syncope focuses on epidemiology, the initial evaluation including risk stratification and disposition from the emergency department, initial diagnostic work-up, management of vasovagal syncope and orthostatic hypotension, and syncope and driving.
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Affiliation(s)
| | - Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos A Morillo
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Juan C Guzman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Hamid S Banijamali
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ciorsti MacIntyre
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jaimie Manlucu
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Colette Seifer
- Division of Cardiology, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - Marco Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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22
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Saad Shaukat MH, Shabbir MA, Banerjee R, Desemone J, Lyubarova R. Is our initial evaluation of patients admitted for syncope guideline-directed and cost-effective? EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-4. [PMID: 32352069 PMCID: PMC7180576 DOI: 10.1093/ehjcr/ytaa032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/21/2019] [Accepted: 01/24/2020] [Indexed: 11/28/2022]
Abstract
Introduction Recent American College of Cardiology and European Society of Cardiology guidelines for syncope evaluation help distinguish high-cardiac risk patients from those with low-risk orthostatic and neurogenic syncope. Inpatient evaluation is recommended if at least one high-risk feature is present. Objective To assess guideline adherence and its impact on hospitalization in patients who presented with syncope before and after the introduction of guideline-based syncope protocol in the emergency department (ED). Methods All adult patients admitted to general medicine from the ED with the primary diagnosis of syncope in the months of October 2016 and October 2018 (before and after the introduction of syncope protocol in 2017). Electronic charts were retrospectively reviewed for high-risk cardiac features and orthostatic blood pressure measurement. Results Sixty patients were admitted for syncope in October 2016 (n = 32) and October 2018 (n = 28), out of which 33 (55%) were female and 47 (78.3%) were over age 50. Forty-five patients had at least one high-risk feature. Excluding one patient with an alternate diagnosis at discharge, 14 out of 60 patients (23.3%) admitted for syncope did not have any high-risk feature. Orthostatic blood pressure was measured in 3 patients (5%) in the ED and 27 patients (45%) later in the hospitalization. Six out of eight patients with implanted cardioverter-defibrillator or pacemaker had their devices interrogated. After the introduction of syncope protocol, there was an improvement in the proportion of high-risk patients admitted [68.7% (22/32) in October 2016 vs. 82.1% (23/28) in October 2018]. Conclusion Utilizing syncope protocol in the ED may improve guideline adherence, direct appropriate disposition, and reduce healthcare expenses.
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Affiliation(s)
- Muhammad Hamza Saad Shaukat
- Department of Internal Medicine, Albany Medical College, Graduate Medical Education, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Muhammad Asim Shabbir
- Department of Internal Medicine, Albany Medical College, Graduate Medical Education, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Riju Banerjee
- Division of Cardiology, Albany Medical College, 43 New Scotland Avenue, Albany NY 12208, USA
| | - James Desemone
- Division of Endocrinology, Albany Medical College, 43 New Scotland Avenue, Albany NY 12208, USA
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, 43 New Scotland Avenue, Albany NY 12208, USA
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Solbiati M, Dipaola F, Villa P, Seghezzi S, Casagranda I, Rabajoli F, Fiorini E, Porta L, Casazza G, Voza A, Barbic F, Montano N, Furlan R, Costantino G. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med 2020; 27:15-23. [PMID: 31854141 DOI: 10.1111/acem.13842] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/14/2019] [Accepted: 07/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Arrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED. METHODS This prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration. RESULTS Of 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients. CONCLUSIONS Although the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
| | - Franca Dipaola
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Paolo Villa
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Luigi Sacco Milano
| | - Sonia Seghezzi
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Niguarda Milano Italy
| | - Ivo Casagranda
- Dipartimento di Emergenza ed Accettazione Azienda Ospedaliera “Santi Antonio e Biagio e C. Arrigo,” Alessandria
| | | | - Elisa Fiorini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
| | - Lorenzo Porta
- UOC Medicina d'Urgenza e Pronto Soccorso Ospedale Luigi Sacco Milano
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche “L. Sacco,” Università degli Studi di Milano Milano
| | - Antonio Voza
- Emergency Department IRCCS Humanitas Research Hospital Rozzano
| | - Franca Barbic
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Nicola Montano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Medicina Generale–Immunologia e Allergologia Milano Italy
| | - Raffaello Furlan
- Internal Medicine, Syncope Unit IRCCS Humanitas Research Hospital Humanitas University Rozzano
| | - Giorgio Costantino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico UOC Pronto Soccorso e Medicina d'Urgenza Milano
- Dipartimento di Scienze Cliniche e di Comunità Università degli Studi di Milano Milano
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24
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Sandhu RK, Sheldon RS. Syncope in the Emergency Department. Front Cardiovasc Med 2019; 6:180. [PMID: 31850375 PMCID: PMC6901601 DOI: 10.3389/fcvm.2019.00180] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/18/2019] [Indexed: 12/02/2022] Open
Abstract
Syncope is a common presentation to Emergency Departments (EDs). Estimates on the frequency of visits (0.6–1.7%) and subsequent rates of hospitalizations (12–85%) vary according to country. The initial ED evaluation for syncope consists of a detailed history, physical examination and 12-lead electrocardiogram (ECG). The use of additional diagnostic testing and specialist evaluation should be based on this initial evaluation rather than an unstructured approach of broad-based testing. Risk stratification performed in the ED is important for estimating prognosis, triage decisions and to establish urgency of any further work-up. The primary approach to risk stratification focuses on identifying high- and low-risk predictors. The use of prediction tools may be used to aid in physician decision-making; however, they have not performed better than the clinical judgment of emergency room physicians. Following risk stratification, decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities. For those deemed intermediate risk, access to specialist assessment and related testing may occur in a syncope unit in the emergency department, as an outpatient, or in a less formal care pathway and is highly dependent on the local healthcare system. For syncope patients presenting to the ED, ~0.8% die and 10.3% suffer a non-fatal severe outcome within 30 days.
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Affiliation(s)
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Walsh KE, Goldberger ZD. Syncope units: An emerging paradigm. Pacing Clin Electrophysiol 2019; 42:828-829. [DOI: 10.1111/pace.13701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Kathleen E. Walsh
- Department of MedicineUniversity of Wisconsin School of Medicine and Public Health
- Division of Cardiovascular Medicine
- Division of Geriatric Medicine
| | - Zachary D. Goldberger
- Department of MedicineUniversity of Wisconsin School of Medicine and Public Health
- Division of Cardiovascular Medicine
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26
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White JL, Hollander JE, Pines JM, Mullins PM, Chang AM. Electrocardiogram and cardiac testing among patients in the emergency department with seizure versus syncope. Clin Exp Emerg Med 2019; 6:106-112. [PMID: 31261481 PMCID: PMC6614053 DOI: 10.15441/ceem.18.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/06/2018] [Indexed: 11/23/2022] Open
Abstract
Objective Cardiogenic syncope can present as a seizure. The distinction between seizure disorder and cardiogenic syncope can only be made if one considers the diagnosis. Our main objective was to identify whether patients presenting with a chief complaint (reason for visit) as seizure or syncope received an electrocardiogram in the emergency department across all age groups. Methods We conducted a secondary analysis of data collected in the 2010 to 2014 National Hospital Ambulatory Medical Care Survey comparing patients presenting with a chief complaint of syncope versus seizure to determine likelihood of getting an evaluation for possible life threatening cardiovascular disease. The primary endpoint was receiving an electrocardiogram in the emergency department; secondary endpoint was receiving cardiac biomarkers. Results There was a total of 144,094 patient encounters. Of these visits, 1,553 had syncope and 1,470 had seizure (60.3% vs. 44.2% female, 19.9% vs. 29.0% non-white). After adjusting for age, sex, mode of arrival and insurance, patients with syncope were more likely to receive an electrocardiogram compared to patients with seizure (odds ratio, 10.86; 95% confidence interval [CI], 8.52 to 13.84). This was true across all age groups (0 to 18 years, 56% vs. 7.5%; 18 to 44 years, 60% vs. 27%; 45 to 64 years, 82% vs. 41%; ≥65 years, 85% vs. 68%; P<0.01 for all). Car- diac biomarkers were also obtained more frequently in adult patients with syncope patients (18 to 44 years, 17.5% vs. 10.5%; 45 to 64 years, 33.8% vs. 21.4%; ≥65 years, 47.1% vs. 32.3%; P<0.01 for all). Conclusion Patients evaluated in the emergency department for syncope received an electrocar- diogram and cardiac biomarkers more frequently than those that had seizure.
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Affiliation(s)
- Jennifer L White
- Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Peter M Mullins
- Department of Emergency Medicine, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Anna Marie Chang
- Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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The prevalence of unexplained falls and syncope in older adults presenting to an Irish urban emergency department. Eur J Emerg Med 2019; 26:100-104. [PMID: 29465466 DOI: 10.1097/mej.0000000000000548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM There is growing evidence of an overlap between unexplained falls and syncope in older adults. Our aim was to examine the prevalence and associated resource utilization of these conditions in an urban emergency department (ED). PATIENTS AND METHODS A single-centre, prospective, observational study was carried out over a 6-month period. Consecutive patients older than 50 years who presented to the ED because of a fall, collapse or syncope were included. Univariate analysis of demographic data is presented as percentages, mean (SD), 95% confidence intervals (CIs) and medians (interquartile range). Logistic regression modelling was used to examine the association between falls and resource utilization. RESULTS A total of 561 patients fulfilled the inclusion criteria during the study period. Unexplained fallers accounted for 14.3% (n=80; 95% CI: 13.3-15.3) and syncope for 12.7% (n=71; 95% CI: 11.7-13.6) of all fall presentations. Overall, 50% (n=282; 95% CI: 48.20-52.34) of patients required admission to hospital. Patients with syncope [odds ratio (OR)=2.48, 95% CI: 1.45-4.23], and unexplained falls (OR=2.36, 95% CI: 1.37-4.08) were more likely to require admission than those with an explained falls. Unexplained fallers were nearly five times more likely to suffer recurrent falls (OR=4.97, 95% CI: 2.89-8.56). CONCLUSION One in four older fallers presenting to ED have symptoms suggestive of syncope or an unexplained fall. There are significant biological consequences of recurrent falls including greater rates of cognitive decline, gait and mobility disturbances, depression and frailty. Recognition that syncope can present as an unexplained fall in older adults is important to ensure that appropriate early modifiable interventions are initiated.
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Numeroso F, Mossini G, Lippi G, Cervellin G. Emergency department management of patients with syncope according to the 2018 ESC guidelines: Main innovations and aspect deserving a further improvement. Int J Cardiol 2019; 283:119-121. [PMID: 30826198 DOI: 10.1016/j.ijcard.2019.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 11/26/2022]
Abstract
The approach suggested by the 2018 ESC GL is the main road for achieving the ambitious goal "zero admission for syncope". This document has in fact introduced a clear-cut distinction between syncope associated with a definite diagnosis, which shall be managed according to the underlying condition, and the really undetermined cases, which shall be managed with prognostic stratification. ESC GL also emphasize the pivotal importance of managing patients in facilities such as ED observation syncope units or outpatient syncope clinics, as a safe alternative to admission. Moreover, they provide a table of non-syncopal causes of TLOC to be excluded, indicating the clinical features distinguishing them from syncope, clearly define the indications for additional examinations to be made after the initial evaluation and include a detailed table contains features for stratifying patients as being at high- and low-risk. However, we believe that this approach could be further improved, by especially defining criteria to identify patient neither high nor low risk, to be called at "intermediate-risk", making the prognostic stratification table easier to remember and use, by clarifying the role of laboratory tests to support the clinical judgment and by defining protocol for managing patients ED observation unit.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, Academic Hospital of Parma, via Gramsci 14, 43126 Parma, Italy.
| | - Gianluigi Mossini
- Emergency Department, Academic Hospital of Parma, via Gramsci 14, 43126 Parma, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Policlinico G.B. Rossi, Borgo Roma, Piazzale L. Scuro, 10-37134 Verona, Italy
| | - Gianfranco Cervellin
- Emergency Department, Academic Hospital of Parma, via Gramsci 14, 43126 Parma, Italy
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Probst MA, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis. Ann Emerg Med 2019; 74:260-269. [PMID: 31080027 DOI: 10.1016/j.annemergmed.2019.03.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/13/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days. METHODS We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (≥60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days. RESULTS We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%). CONCLUSION In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Erica Su
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Robert E Weiss
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Annick N Yagapen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Susan E Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - David H Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital-Troy, Troy, MI
| | | | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carol L Clark
- Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Bret A Nicks
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
| | - Manish N Shah
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI
| | - Kirk A Stiffler
- Department of Emergency Medicine, Northeastern Ohio Medical University, Rootstown, OH
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Scott T Wilber
- Department of Emergency Medicine, Northeastern Ohio Medical University, Rootstown, OH
| | - Benjamin C Sun
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
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Mechanic OJ, Pascheles CY, Lopez GJ, Winans AM, Shapiro NI, Tibbles C, Wolfe RE, Grossman SA. Using the Boston Syncope Observation Management Pathway to Reduce Hospital Admission and Adverse Outcomes. West J Emerg Med 2019; 20:250-255. [PMID: 30881544 PMCID: PMC6404692 DOI: 10.5811/westjem.2018.11.39657] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/26/2018] [Accepted: 11/21/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction In an age of increasing scrutiny of each hospital admission, emergency department (ED) observation has been identified as a low-cost alternative. Prior studies have shown admission rates for syncope in the United States to be as high as 70%. However, the safety and utility of substituting ED observation unit (EDOU) syncope management has not been well studied. The objective of this study was to evaluate the safety of EDOU for the management of patients presenting to the ED with syncope and its efficacy in reducing hospital admissions. Methods This was a prospective before-and-after cohort study of consecutive patients presenting with syncope who were seen in an urban ED and were either admitted to the hospital, discharged, or placed in the EDOU. We first performed an observation study of syncope management and then implemented an ED observation-based management pathway. We identified critical interventions and 30-day outcomes. We compared proportions of admissions and adverse events rates with a chi-squared or Fisher’s exact test. Results In the “before” phase, 570 patients were enrolled, with 334 (59%) admitted and 27 (5%) placed in the EDOU; 3% of patients discharged from the ED had critical interventions within 30 days and 10% returned. After the management pathway was introduced, 489 patients were enrolled; 34% (p<0.001) of pathway patients were admitted while 20% were placed in the EDOU; 3% (p=0.99) of discharged patients had critical interventions at 30 days and 3% returned (p=0.001). Conclusion A focused syncope management pathway effectively reduces hospital admissions and adverse events following discharge and returns to the ED.
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Affiliation(s)
- Oren J Mechanic
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Celine Y Pascheles
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Gregory J Lopez
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alina M Winans
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Nathan I Shapiro
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Carrie Tibbles
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Richard E Wolfe
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Shamai A Grossman
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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The Results of Randomized Controlled Trials in Emergency Medicine Are Frequently Fragile. Ann Emerg Med 2018; 73:565-576. [PMID: 30551894 DOI: 10.1016/j.annemergmed.2018.10.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Randomized controlled trials govern evidence-based clinical practice, and it is therefore critical that their results be robust. We aim to investigate the fragility of randomized controlled trials in emergency medicine by determining how often significance would be nullified with small changes in outcomes using the fragility index. METHODS We conducted a methodological systematic review of randomized controlled trials in emergency medicine published in the top 10 general medicine journals and the top 10 emergency medicine journals. Inclusion criteria required that trials be emergency medicine studies structured with a 2-arm or 2-by-2 factorial design and report at least 1 statistically significant dichotomous outcome. RESULTS A total of 180 trials met inclusion criteria. The median fragility index across all trials in emergency medicine was 4 (interquartile range [IQR] 2 to 10) and the median sample size was 140 (IQR 69.5 to 286). For trials from general medicine journals (n=32), the median fragility index was 9 (IQR 4 to 16.5) and the median sample size was 415.5 (IQR 219.5 to 901); for trials from emergency medicine journals (n=148), the median fragility index was 4 (IQR 1 to 9) and the median sample size was 119 (IQR 60 to 227.25). One third of all trials (62/180) had a loss to follow-up that was greater than or equal to the fragility index. There was a modest correlation between fragility index and total number of events (r=0.36; 95% confidence interval [CI] 0.23 to 0.48) and a weak correlation between fragility index and total sample size (r=0.26; 95% CI 0.12 to 0.39). There was no correlation between fragility index and either P value (r=-0.14; 95% CI -0.28 to -0.006) or Science Citation Index (r=0.07; 95% CI -0.08 to 0.22). CONCLUSION The statistical significance of the results of randomized controlled trials in emergency medicine was often contingent on a small number of events. Until frequentist interpretation of clinical trials is replaced with Bayesian analysis, the fragility index may have utility as a tool to aid clinicians in assessing the robustness of randomized controlled trials in emergency medicine when considered in conjunction with the fragility quotient and other reported metrics.
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Satish M, Walters RW, Alla VM. Trends in use of echocardiography in hospitalized patients with syncope. Echocardiography 2018; 36:7-14. [PMID: 30479042 DOI: 10.1111/echo.14208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/11/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023] Open
Abstract
PURPOSE We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database. METHODS Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18 years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained. RESULTS A total of 3 174 619 patients with a primary discharge diagnosis of syncope were identified, of which 184 167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [Ptrend = 0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR = 0.827, P = 0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P < 0.001). CONCLUSIONS The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope.
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Affiliation(s)
- Mohan Satish
- Creighton University School of Medicine, Omaha, Nebraska
| | - Ryan W Walters
- Creighton University School of Medicine, Omaha, Nebraska
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33
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Trends in Hospitalization, Readmission, and Diagnostic Testing of Patients Presenting to the Emergency Department With Syncope. Ann Emerg Med 2018; 72:523-532. [DOI: 10.1016/j.annemergmed.2018.08.430] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/26/2018] [Accepted: 08/13/2018] [Indexed: 11/20/2022]
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Strøm C, Rasmussen LS, Löwe AS, Lorentzen AK, Lohse N, Madsen KHB, Rasmussen SW, Schmidt TA. Short-stay unit hospitalisation vs. standard care outcomes in older internal medicine patients-a randomised clinical trial. Age Ageing 2018; 47:810-817. [PMID: 29905758 DOI: 10.1093/ageing/afy090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Indexed: 02/04/2023] Open
Abstract
Background the effect of hospitalisation in emergency department-based short-stay units (SSUs) has not been studied in older patients. We compared SSU hospitalisation with standard care at an Internal Medicine Department (IMD) in acutely admitted older internal medicine patients. Methods pragmatic randomised clinical trial. We randomly assigned patients aged 75 years or older, acutely admitted for an internal medicine disease and assessed to be suitable for SSU hospitalisation to SSU hospitalisation or IMD hospitalisation. SSU hospitalisation was provided by a pragmatic 'fast-track' principle. The primary outcome was 90-day mortality. Secondary outcomes included adverse events, change in Lawton Instrumental Activities of Daily Living (IADL) score within 90 days from admission, in-hospital length of stay and unplanned readmissions within 30 days after discharge. Results between January 2015 and October 2016, 430 participants were randomised (median age 84 years in both groups). Ninety-day mortality was 22(11%) in the SSU group and 32(15%) in the IMD group (odds ratio (OR) 0.66; 95% confidence interval (CI) 0.37-1.18; P = 0.16). When comparing the SSU group to the IMD group, 16(8%) vs. 45(21%) experienced at least one adverse event (OR 0.31; 95% CI 0.17-0.56; P < 0.001); 6(3%) vs. 35(20%) experienced a reduction in IADL score within 90 days from admission (P < 0.001); median in-hospital length of stay was 73 h [interquartile range, IQR 36-147] vs. 100 h [IQR 47-169], (P < 0.001), and 26(13%) vs. 58(29%) were readmitted (OR 0.37; 95% CI 0.22-0.61; P < 0.001). Conclusions mortality at 90 days after admission was not significantly lower in the SSU group, but SSU hospitalisation was associated with a lower risk of adverse events, less functional decline, fewer readmissions and shorter hospital stay. Trial registration NCT02395718.
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Affiliation(s)
- Camilla Strøm
- Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Sophie Löwe
- Department of Emergency Medicine, North Denmark Regional Hospital, Hjoerring, Denmark
| | - Anne Kathrine Lorentzen
- Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark
| | - Nicolai Lohse
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kim Hvid Benn Madsen
- Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark
| | | | - Thomas Andersen Schmidt
- Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Oebel S, Hindricks G. [Management of syncope in clinical practice : What has changed according to the new ESC guidelines 2018?]. Herz 2018; 43:701-709. [PMID: 30341445 DOI: 10.1007/s00059-018-4757-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Syncope is a common problem in clinical practice, which affects approximately 1% of patients admitted to European emergency departments. The clinical practice guidelines for the diagnosis and management of syncope published by the European Society of Cardiology (ESC) are based on the newest scientific data in the field and have provided clinical cardiologists with a structured therapeutic approach for affected patients over many years. The previous ESC guidelines on syncope were published in 2009 and are compared to the most recent edition, which was published in 2018. This review summarizes the most important innovations with respect to the diagnostic principles and treatment of syncope. The initial assessment of the patient and the risk stratification in the emergency department are the focus of the review. Another important topic that is adequately covered in the current guidelines is the rising significance of implantable loop recorders for the evaluation of unexplained syncope and the assessment of potential indications for a definitive treatment with a pacemaker or implantable cardioverter defibrillator (ICD). Additional changes involve the evidence level with respect to the use of other diagnostic (ECG monitoring, tilt testing) and therapeutic measures (indications for pacemaker implantation, catheter ablation of tachycardiac rhythm disorders).
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Affiliation(s)
- S Oebel
- Abteilung für Rhythmologie, HELIOS Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Deutschland
| | - G Hindricks
- Abteilung für Rhythmologie, HELIOS Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Deutschland.
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Use of a Pediatric Syncope Unit Improves Diagnosis and Lowers Costs: A Hospital-Based Experience. J Pediatr 2018; 201:184-189.e2. [PMID: 29961647 DOI: 10.1016/j.jpeds.2018.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/26/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the effect of a dedicated pediatric syncope unit on the diagnostic and therapeutic management of children with suspected syncope. We also evaluated the effectiveness of the pediatric syncope unit model in decreasing unnecessary tests and hospitalizations, minimizing social costs, and improving diagnostic yield. STUDY DESIGN This single-center cohort observational, prospective study enrolled 2278 consecutive children referred to Bambino Gesù Children's Hospital from 2012 to 2017. Characteristics of the study population, number and type of admission examinations, and diagnostic findings before the pediatric syncope unit was implemented (2012-2013) and after the pediatric syncope unit was implemented (2014-2015 and 2016-2017) were compared. RESULTS The proportion of undefined syncope, number of unnecessary diagnostic tests performed, and number of hospital stay days decreased significantly (P < .0001), with an overall decrease in costs. A multivariable logistic regression analysis, adjusted for confounding variables (age, sex, number of diagnostic tests), the period after pediatric syncope unit (2016-2017) resulted as the best independent predictor of effectiveness for a defined diagnosis of syncope (P < .0001). CONCLUSIONS Pediatric syncope unit organization with fast-tracking access more appropriate diagnostic tests is effective in terms of accuracy of diagnostic yield and reduction of costs.
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Muresan L, Cismaru G, Martins RP, Bataglia A, Rosu R, Puiu M, Gusetu G, Mada RO, Muresan C, Ispas DR, Le Bouar R, Diene LL, Rugina E, Levy J, Klein C, Sellal JM, Poull IM, Laurent G, de Chillou C. Recommendations for the use of electrophysiological study: Update 2018. Hellenic J Cardiol 2018; 60:82-100. [PMID: 30278230 DOI: 10.1016/j.hjc.2018.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/31/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published. The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic. For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed. Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases. In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures.
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Affiliation(s)
- Lucian Muresan
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France.
| | - Gabriel Cismaru
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Raphaël Pedro Martins
- Centre Hospitalier Universitaire de Rennes, Cardiology Department, 35000 Rennes, France
| | - Alberto Bataglia
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Radu Rosu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Mihai Puiu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Gabriel Gusetu
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Razvan Olimpiu Mada
- "Niculae Stancioiu" Heart Institute, Cardiology Department, 400005 Cluj-Napoca, Romania
| | - Crina Muresan
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Daniel Radu Ispas
- Rehabilitation Hospital, Cardiology Department, 400347 Cluj-Napoca, Romania
| | - Ronan Le Bouar
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | | | - Elena Rugina
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Jacques Levy
- "Emile Muller" Hospital, Cardiology Department, 68100 Mulhouse, France
| | - Cedric Klein
- Centre Hospitalier Universitaire de Lille, Cardiology Department, 59000 Lille, France
| | - Jean Marc Sellal
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Isabelle Magnin Poull
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
| | - Gabriel Laurent
- Centre Hospitalier Universitaire de Dijon, Cardiology Department, 21000 Dijon, France
| | - Christian de Chillou
- Institut Lorrain du Coeur et des Vaisseaux « Louis Mathieu », Cardiology Department, Electrophysiology Department, 54000 Vandoeuvre-les-Nancy, France
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Deif B, Kang S, Ismail A, Vanniyasingam T, Guzman JC, Morillo CA. Application of Syncope Guidelines in the Emergency Department Do Not Reduce Admission Rates: A Retrospective Cohort Study. Can J Cardiol 2018; 34:1158-1164. [PMID: 30170671 DOI: 10.1016/j.cjca.2018.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 06/26/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Low-risk syncope accounts for a large proportion of hospital admissions; however, inpatient investigations are often not necessary and are rarely diagnostic. Reducing the number of low-risk syncope admissions can likely lower health care resource consumption and overall expenditure. Application of syncope guidelines by physicians in the emergency department provides a standardized approach that may potentially reduce admissions and lead to health care resource utilization savings. METHODS A retrospective chart review of 1229 syncope presentations was conducted at 2 major academic centres spanning 1 year. Three major society guidelines and position statements were applied to determine the effect on admission rates. RESULTS A total of 1031 true syncope charts were included in the analysis; 407 (39%) were admitted and 624 (61%) were discharged by the treating physician (MD). There was a significant difference in the mean [standard deviation] age (75 [14] vs 55 [22]) and baseline cardiovascular disease, including congestive heart failure 51/407 (13%) vs 28/624 (5%), coronary artery disease 125/407 (31%) vs 91/624 (15%), and structural heart disease 36/407 (9%) vs 26/624 (4%), between admitted and not admitted patients, respectively (P < 0.01). All guidelines warranted more low-risk admissions when compared with 19% by the MD: Canadian Cardiovascular Society 34% (P < 0.01), American College of Emergency Physicians 22% (P = 0.03), and European Society of Cardiology 26% (P < 0.01). CONCLUSION In conclusion, application of the current syncope guidelines to an emergency department population is unlikely to reduce low-risk hospital admissions.
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Affiliation(s)
- Bishoy Deif
- Department of Medicine, Division of Cardiology, Western University, London, Ontario, Canada
| | - Sally Kang
- Undergraduate Medical Program, University of Toronto, Toronto, Ontario, Canada
| | - Abid Ismail
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thuva Vanniyasingam
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Juan C Guzman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
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Sabbatini AK, Wright B, Hall MK, Basu A. The cost of observation care for commercially insured patients visiting the emergency department. Am J Emerg Med 2018; 36:1591-1596. [DOI: 10.1016/j.ajem.2018.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
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Strøm C, Stefansson JS, Fabritius ML, Rasmussen LS, Schmidt TA, Jakobsen JC. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev 2018; 8:CD012370. [PMID: 30102428 PMCID: PMC6513218 DOI: 10.1002/14651858.cd012370.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions. OBJECTIVES To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies. SELECTION CRITERIA We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach. MAIN RESULTS We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs. AUTHORS' CONCLUSIONS Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.
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Affiliation(s)
- Camilla Strøm
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Jakob S Stefansson
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Maria Louise Fabritius
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Lars S Rasmussen
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Thomas A Schmidt
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Abulhamayel A, Savu A, Sheldon RS, Kaul P, Sandhu RK. Geographical Differences in Comorbidity Burden and Outcomes in Adults With Syncope Hospitalizations in Canada. Can J Cardiol 2018; 34:937-940. [PMID: 29960620 DOI: 10.1016/j.cjca.2018.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 11/20/2022] Open
Abstract
A recent study found that rates of hospitalization for syncope vary across provinces; however, it is unknown whether differences in comorbidity burden and outcomes also exist. The Canadian Institute for Health Information Discharge Abstract Database was used to identify primary syncope hospitalizations (ICD-10 code R55) from 2004 to 2013 for all provinces (except Quebec). Charlson comorbidity score was calculated from comorbidities at the time of hospitalization. Outcomes were defined as in-hospital mortality, 30-day readmission for any cause, and syncope. Logistic regression models were constructed for odds ratios (ORs) and 95% confidence intervals (CIs) to estimate interprovincial differences in outcomes. The interprovincial range (IPR) for mean age was 61.1 ± 17.5 to 73.7 ± 16.3 years, and at least half were male patients. There were significant differences in comorbidity burden across provinces (P < 0.01); however, the majority of patients had a Charlson comorbidity score = 0 (IPR, 53.9%- 71.9%). In multivariable analysis, compared with Ontario, in-hospital mortality was higher for British Columbia (OR, 1.59; 95% CI, 1.22-2.06), Nova Scotia (OR, 1.67; 95% CI, 1.05-2.65), and Newfoundland (OR, 2.27; 95% CI, 1.29-4.00); 30-day readmission for any cause was higher for British Columbia (OR, 1.15; 95% CI, 1.06-1.26), Alberta (OR, 1.19; 95% CI, 1.07-1.31), Manitoba (OR, 1.36; 95% CI, 1.18-1.56), and Prince Edward Island (OR, 1.38; 95% CI, 1.0-1.89), and all outcomes were higher in Saskatchewan. There is significant interprovincial heterogeneity in comorbidity burden and outcomes for hospitalizations for syncope. Future research evaluating whether standardized practices for management of syncope reduce variability and improve healthcare utilization and costs is needed.
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Affiliation(s)
- Ahmed Abulhamayel
- University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Padma Kaul
- University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Roopinder K Sandhu
- University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada.
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Affiliation(s)
- Josh Waytz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
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Solbiati M, Bozzano V, Barbic F, Casazza G, Dipaola F, Quinn JV, Reed MJ, Sheldon RS, Shen WK, Sun BC, Thiruganasambandamoorthy V, Furlan R, Costantino G. Outcomes in syncope research: a systematic review and critical appraisal. Intern Emerg Med 2018; 13:593-601. [PMID: 29349639 DOI: 10.1007/s11739-018-1788-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
Abstract
Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus. We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment. 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse. We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.
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Affiliation(s)
- Monica Solbiati
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy.
| | | | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University-Humanitas Research Hospital, Rozzano, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Franca Dipaola
- Department of Biomedical Sciences, Humanitas University-Humanitas Research Hospital, Rozzano, Italy
| | - James V Quinn
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert S Sheldon
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | | | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University-Humanitas Research Hospital, Rozzano, Italy
| | - Giorgio Costantino
- Dipartimento di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
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Numeroso F, Mossini G, Lippi G, Cervellin G. Syncope: current knowledge, uncertainties and strategies for management optimisation in the emergency department. Acta Cardiol 2018; 73:215-221. [PMID: 28799452 DOI: 10.1080/00015385.2017.1362146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Admission rates and expenditures for syncope remain high. This unsatisfactory management could be due to several factors, including lack of evidence-based strategy, poor accuracy of clinical decision rules, difficulty in disseminating guidelines, as well as uncertainties concerning management of intermediate-risk patients and role of observation protocols and syncope units. To optimise management, it has been proposed to adopt a pragmatic, symptoms-based definition of syncope and a classification related to the underlying mechanism rather than suspected aetiology. It has also been emphasised the importance of identifying patients at intermediate risk as they can be safely discharged after an intensive emergency department evaluation. A further improvement might result from a research implementation to validate the role of observation protocols and to select patients amenable to be sent to outpatient syncope units. Finally, future studies on prognostic significance of syncope should be performed with a more careful selection of outcomes and a greater uniformity.
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Affiliation(s)
- Filippo Numeroso
- Department of Emergency, Academic Hospital of Parma, Parma, Italy
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Unterhuber M, Tomaino M, Brignole M. [Do we need syncope units? : Experience from Bolzano, South Tyrol (Italy)]. Herzschrittmacherther Elektrophysiol 2018; 29:199-203. [PMID: 29761334 DOI: 10.1007/s00399-018-0561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/03/2018] [Indexed: 11/28/2022]
Abstract
Syncope is a common cause for presentation to the emergency department. Because of the numerous differential diagnoses which can be life-threatening, it can be a challenging work-up for the physician. This often results in admission rates that are too high and hospital stays that are too long with consequent high costs. Several studies have shown the inferiority of best-clinical practice to an evidence-based approach in syncope work-up, which results in underdiagnosis and often incorrect diagnosis of syncope. The consequences are undirected therapies and subsequently high recurrence rates of syncope, which lead to limited quality of life and readmissions. For this reason, the European Society of Cardiology (ESC) Guidelines for the diagnosis and management of syncope recommend the organization of Syncope Units. Through a standardized and evidence-based approach, the diagnostic and therapeutic work-up can be done in a safe and effective manner, allowing an organized follow-up and further management of patients with syncope. This article summarizes the reasons for the need of syncope units and explains the practical implementation of the guidelines using the example of the Syncope Unit in Bolzano, South Tyrol (Italy).
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Affiliation(s)
- Matthias Unterhuber
- Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland. .,Regionalkrankenhaus Bozen, L. Böhler-Str. 5, 39100, Bozen, Italien.
| | - Marco Tomaino
- Regionalkrankenhaus Bozen, L. Böhler-Str. 5, 39100, Bozen, Italien
| | - Michele Brignole
- Department of Cardiology, Ospedali Tigullio, 16033, Lavagna, Italien
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Anand V, Benditt DG, Adkisson WO, Garg S, George SA, Adabag S. Trends of hospitalizations for syncope/collapse in the United States from 2004 to 2013-An analysis of national inpatient sample. J Cardiovasc Electrophysiol 2018; 29:916-922. [PMID: 29505697 DOI: 10.1111/jce.13479] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/09/2018] [Accepted: 02/23/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Syncope/collapse is a common reason for emergency department visits, and approximately 30-40% of these individuals are hospitalized. We examined changes in hospitalization rates, in-hospital mortality, and cost of syncope/collapse-related hospital care in the United States from 2004 to 2013. METHODS We used the US Nationwide Inpatient Sample (NIS) from 2004 to 2013 to identify syncope/collapse-related hospitalizations using ICD-9, code 780.2, as the principal discharge diagnosis. Data are presented as mean ± SEM. RESULTS From 2004 to 2013, there was a 42% reduction in hospitalizations with a principal discharge diagnosis of syncope/collapse from 54,259 (national estimate 253,591) in 2004 to 31,427 (national estimate 156,820) in 2013 (P < 0.0001). The mean length of hospital stays decreased (2.88 ± 0.04 days in 2004 vs. 2.54 ± 0.02 in 2013; P < 0.0001), while in-hospital mortality did not change (0.28% in 2004 vs. 0.18% in 2013; P = 0.12). However, mean charges (inflation adjusted) for syncope/collapse-related hospitalization increased by 43.6% from $17,514 in 2004 to $25,160 in 2013 (P < 0.0001). The rates of implantation of permanent pacemakers and implantable cardioverter defibrillator remained low during these hospitalizations, and decreased over time (P for both < 0.0001). CONCLUSIONS Hospitalization rates for syncope/collapse have decreased significantly in the US from 2004 to 2013. Despite a modest reduction in length of stay, the cost of syncope/collapse-related hospital care has increased.
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Affiliation(s)
- Vidhu Anand
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - David G Benditt
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Wayne O Adkisson
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Sushil Garg
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Stephen A George
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Selcuk Adabag
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.,Division of Cardiology, Department of Medicine, Minneapolis VA Healthcare System, Minneapolis, MN, USA
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 993] [Impact Index Per Article: 165.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Numeroso F, Mossini G, Lippi G, Cervellin G. Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis. Clin Exp Emerg Med 2017; 4:201-207. [PMID: 29306267 PMCID: PMC5758624 DOI: 10.15441/ceem.17.231] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.
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Affiliation(s)
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines. Eur J Emerg Med 2017; 24:428-434. [DOI: 10.1097/mej.0000000000000392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sandhu RK, Tran DT, Sheldon RS, Kaul P. A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department. JACC Clin Electrophysiol 2017; 4:265-273. [PMID: 29749948 DOI: 10.1016/j.jacep.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/30/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). BACKGROUND ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. METHODS A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. RESULTS Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 million (Cohort 1: $75.3 million; $29,519/patient, Cohort 2: $138.1 million; $42,042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). CONCLUSIONS Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts.
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Affiliation(s)
- Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
| | - Dat T Tran
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert S Sheldon
- Division of Cardiology, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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