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Numeroso F, Casagranda I, Lerza R, Ungar A. Current ED syncope management in Italian hospitals and prospects for optimization: a national survey. Intern Emerg Med 2024; 19:777-786. [PMID: 37962787 DOI: 10.1007/s11739-023-03463-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Ivo Casagranda
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Roberto Lerza
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Andrea Ungar
- Geriatric and Intensive Care Unit, Careggi Hospital and University of Florence, Florence, Italy
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Simos P, Scott I. Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope. Postgrad Med J 2022; 99:postgradmedj-2021-141416. [PMID: 35169024 DOI: 10.1136/postgradmedj-2021-141416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/22/2022] [Indexed: 01/03/2023]
Abstract
STUDY PURPOSE Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary. STUDY DESIGN We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients. RESULTS Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028). CONCLUSION In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.
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Affiliation(s)
- Peter Simos
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia .,School of Clinical Medicine, University of Queensland Faculty of Health and Behavioural Sciences, Herston, Queensland, Australia
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Zaboli A, Ausserhofer D, Sibilio S, Paulmichl R, Toccolini E, Pfeifer N, Brigo F, Turcato G. Triage assessment of transitory loss of consciousness in the emergency department-A retrospective observational study. J Adv Nurs 2021; 78:1337-1347. [PMID: 34532861 DOI: 10.1111/jan.15048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/22/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
AIM To establish how the Manchester Triage System can correctly prioritize patients admitted to the emergency department for transitory loss of consciousness in relation to their risk of presenting severe acute disease. DESIGN A observational retrospective study. METHODS A total of 2291 patients who required a triage evaluation for a transitory loss of consciousness at the emergency department of Merano Hospital between 1 January 2017 and 30 June 2019 were considered. Transitory loss of consciousness was classified according to European Society of Cardiology guidelines. The baseline characteristics of the patients were collected and divided according to the priority level assigned at triage into two different study groups: high priority (red/orange) and low priority (blue/green/yellow). The composite outcome of the study was defined as the diagnosis of a severe acute disease. RESULTS Of the patients enrolled, 17% (390/2291) had a high-priority code and 83% (1901/2291) received a low-priority code. Overall, a severe acute disease was present in 16.9% of patients (387/2291). The Manchester Triage System had a sensitivity of 42.4%, a specificity of 88.1% and an accuracy of 80.4% for predicting severe acute disease. The discriminatory ability had an area under the receiver operating characteristic curve of 0.651 (CI 95%: 0.618-0.685). CONCLUSIONS Despite the good specificity, the low sensitivity does not currently allow the Manchester Triage System to completely exclude patients with a severe acute disease who presented in the emergency department for a transitory loss of consciousness. Therefore, it is important to develop precise nursing tools or assessments that can improve triage performance. IMPACT The assessment of a complex symptom can create difficulties in the stratification of patients in triage, assigning low-priority codes to patients with a severe disease. Additional tools are needed to allow the correct triage assessment of patients presenting with transitory loss of consciousness.
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Affiliation(s)
- Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano, Italy.,Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Serena Sibilio
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Rupert Paulmichl
- Department of Cardiology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Elia Toccolini
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
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Numeroso F, Casagranda I. How to simplify the implementation of Syncope ESC Guidelines in the Emergency Department and get on the road to achieve "zero inappropriate admissions". Minerva Med 2021; 113:228-233. [PMID: 34180642 DOI: 10.23736/s0026-4806.21.07580-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
According to 2018 ESC Guidelines for syncope, the first aim in ED evaluation is to identify patients with underlying acute diseases, at higher risk of short-term adverse events; in the meantime, emergency physicians should also identify cases of hypotensive syncope elicited by non-severe concurrent conditions, as they mostly do not require hospitalization. After excluding these cases, ESC GL state that patients should be managed with initial evaluation and risk stratification, providing several tables and flow-charts to do it. To optimize ED management, authors propose to combine these two phases, as in the clinical practice they occur at the same, with the following simplified paths: patients with only clinical features suggestive of reflex syncope should be discharged, with a fast-track to an outpatient Syncope Unit only in case of severe syncope; patients with orthostatic syncope could be discharged with measures to prevent recurrences or be managed in an ED Observation Unit (EDOU) in case of fluid loss or other causes of volume depletion; patients with major clinical or ECG criteria suggestive of cardiogenic syncope should be admitted, for diagnostic or therapeutic purposes; patients with undetermined syncope or minor clinical or ECG criteria suggestive of cardiogenic syncope should be managed in an EDOU. ESC GL give focus to this novel care pathway but they do not provide clear details on the organizational aspects; accordingly, this document proposes resources and protocols for managing patients in EDOU, as a first part of the functional path of the outpatient Syncope Unit.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Parma, Italy -
| | - Ivo Casagranda
- : Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
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Reducing Hospitalization in Mild Acute Pancreatitis: Results of Long-term Follow-up. J Clin Gastroenterol 2021; 55:180-186. [PMID: 32301837 DOI: 10.1097/mcg.0000000000001354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/11/2020] [Indexed: 01/15/2023]
Abstract
GOALS AND BACKGROUND Acute pancreatitis (AP) is a common emergency department (ED) diagnosis, amounting to enormous costs. Our previous pilot study demonstrated the feasibility of reducing hospitalization using an ED-based observation pathway. In this follow-up study, we hypothesize that the pathway is durable in clinical practice, outside of research supervision, and patients can safely be managed without hospitalization. STUDY We reviewed patients prospectively enrolled in the observation pathway after the end of the pilot study. We compared outcomes to patients enrolled in our pilot study and with a historic cohort of patients admitted with mild AP. Our primary outcome was hospitalization rate during the enrollment period and secondary outcomes included length of stay, 30-day readmissions, mortality, and health care utilization. RESULTS Over a 2-year period 165 patients met criteria for AP with 118 (71.5%) having mild AP. Fifty-four of 118 patients (45.8%) were enrolled in the observation pathway and of these, 45 patients were discharged from the ED, reducing hospitalization by 31.2%, compared with pilot study (22.2%) and historic cohort (0%) (P<0.05). Median length of stay was shorter [19.9 (observation) vs. 72.0 h (historic cohort), P<0.01]. There were fewer radiographic examinations in the observation cohorts (pilot and current study) than in the historic cohort (P<0.05), with similar 30-day readmissions, and no reported deaths. CONCLUSIONS This follow-up study demonstrates the durability of an observation-based pathway to manage mild AP outside of a research protocol and maintain its ability to reduce hospitalizations without affecting readmission rates or mortality.
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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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Qian XL, Pan YS, Chen JJ, Jiang QQ, Huang D, Li JB. The value of multidisciplinary team in syncope clinic for the effective diagnosis of complex syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:821-827. [PMID: 31004502 DOI: 10.1111/pace.13703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Syncope is a perplexing challenge that often receives thorough evaluation, yet the diagnosis remains unclear. Usually, the emergency department is the first point at which patients present with syncope. However, diverse medical factors, including low diagnostic rates and inconsistent management by doctors, add to healthcare costs and delay diagnosis for syncope patients. METHODS Patients who had been to the emergency department at least once but were not given a clear diagnosis of syncope were recruited into our study at the time they visited syncope clinic staffed by a multidisciplinary team. Complete medical histories and clinical examinations were conducted by both experienced cardiologists and neurologists. If patients were not given a conclusive diagnosis at the syncope clinic on the basis of outpatient examinations, they were admitted for further evaluation. RESULTS A total of 209 consecutive patients claiming "syncope" visited the syncope clinic, yet only 167 patients were formally diagnosed with syncope. For these 167 patients, the mean age was 55.93 ± 17.40 years old, and 41.3% were male. The proportions of cardiac syncope, reflex syncope, orthostatic hypotension (OH), and syncope of uncertain etiology were 19.8%, 64.1%, 7.8%, and 8.4%, respectively. The diagnostic rate was 91.6%, and the hospitalization rate was 23.4%. Patients with reflex syncope and OH were younger than patients with cardiac syncope. Cardiac syncope tends to occur more frequently in males, while reflex syncope is more likely in females. CONCLUSIONS The cooperation of professional cardiologists and neurologists will play an important role in improving diagnostic rates, lowering admission rates, and reducing medical costs.
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Affiliation(s)
- Xiao-Lin Qian
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Ye-Sheng Pan
- Heart Center, Tongji University Affiliated Oriental Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Jing-Jiong Chen
- Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Qing-Qing Jiang
- Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Dong Huang
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
| | - Jing-Bo Li
- Heart Center, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China
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