Is our initial evaluation of patients admitted for syncope guideline-directed and cost-effective?

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.

The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments

“…These results highlight the importance of negative-structured ED evaluation to identify patients who can be safely discharged to reduce the associated healthcare costs [28]. It was found that adherence to the syncope guidelines helped to improve decision-making, aided in terms of deciding the appropriate disposition of syncope patients, and reduced resource utilization and healthcare expenses [15]. Moreover, prolonged EKG monitoring (>12 hours) of syncope patients was proposed to have high accuracy in identifying the major cardiovascular events seven and 30 days after the ED visit [13].…”

“…Over the past decade, substantial efforts by medical researchers and professional societies have been undertaken to increase the accuracy of decision-making regarding syncope patients making ED visits. These efforts include the development of new policies and guidelines, developing risk scores to identify at-risk patients, prolonged EKG monitoring for cardiovascular events, and extensive examination and history taking from syncope patients [13][14][15][16].…”