Study Hypothesis
Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly with little evidence of benefit. We hypothesized that an Emergency Department Observation Syncope Protocol would reduce resource use without adversely affecting patient-oriented outcomes.
Methods
This randomized trial at five EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near-syncope. Primary outcomes included inpatient admission rate and length-of-stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.
Results
Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% vs. 92%, 95%CI Difference: −88%, −66%) and shorter hospital length-of-stay (29 vs. 47 hours, 95%CI Difference: −28, −8). Serious outcome rates after hospital discharge were similar for observation vs. admission at 30-days (3% vs. 0%, 95%CI Difference: −1%, 8%) and 6-months (8% vs. 10%, 95%CI Difference: −13%, 9%). Index hospital costs in the observation group were $629 (95%CI Difference: −$1376, −$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.
Conclusions
An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length-of-stay. Analyses of secondary outcomes suggest reduction in index hospital costs with no difference in safety events, quality-of-life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.
Screening for alcohol misuse and identifying patients engaged in hazardous drinking meet important nurse practitioner competencies. Further research is needed to explore training programs that specifically emphasize activities to increase perceived competence, knowledge, and comfort regarding SBIRT.
By removing cost, time, transportation, and bureaucratic barriers, the program was able to reach more children than fixed-site clinics. The program was a merging of private and public health dentistries. This model can be useful to other communities in light of the unmet need for dental care and tighter federal, state, and local government budgets.
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