Patient Care

ED Observation Syncope Protocol Reduces Resource Use Without Compromising Safety


Clinical question: Can an ED observation syncope protocol decrease resource utilization without adversely affecting outcomes?

Background: Syncope is a common complaint in EDs. Uncertainty in the best way to manage older adults at intermediate risk for adverse outcomes results in frequent, costly hospitalizations without clear improvement in outcomes. An observation syncope protocol may standardize care and reduce admissions without worsening safety.

Study design: Randomized, non-blinded, clinical trial.

Setting: Five EDs in the United States.

Synopsis: One hundred twenty-four intermediate-risk adults (≥50 years) presenting with syncope or near syncope were randomized to an ED observation syncope protocol vs. routine admission. The observation protocol resulted in a lower admission rate (15% vs. 92%), shorter stay (29 vs. 47 hours), and decreased index hospital costs ($629); however, there were no significant differences in serious outcomes after discharge at 30 days (3% vs. 0%) or six months (8% vs. 10%), 30-day quality of life scores, or patient satisfaction. Limitations include the small study size, the fact that half of eligible patients were excluded as high risk, higher number of abnormal ECGs in the control group, and a cost savings that was attenuated at 30 days.

This ED observation syncope protocol demonstrated an impressive decrease in admission rates and length of stay without compromising safety, but only a small fraction of patients met the inclusion criteria, and the cost savings were small and transient.

Bottom line: An ED observation syncope protocol for intermediate-risk patients decreased admission rates, length of stay, and index hospitalization costs without a difference in safety events, patient satisfaction, or quality of life.

Citation: Sun BC, McCreath H, Liang L, et al. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission [published online ahead of print November 13, 2013]. Ann Emerg Med.

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