Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department

doi:10.1016/j.ahj.2004.07.024

American Heart Journal

Volume 149, Issue 5, May 2005, Pages 826-831

https://doi.org/10.1016/j.ahj.2004.07.024 Get rights and content

Background

The goal of our study was to determine the accuracy of the American College of Emergency Physicians (ACEP) clinical policy in identifying patients with a cardiac cause for their syncope and its potential effect on syncope management.

Methods

Adult patients with syncope presenting to the emergency department (ED) from January 1996 to December 1998 were identified. Diagnosis was established retrospectively by reviewing medical records. The ACEP guidelines were applied to this population.

Results

Of the 200 patients identified, 115 (57.5%, 95% CI 60-64) were admitted from the ED and 24 (12%) were found to have cardiogenic syncope. Of the 24 patients with cardiac syncope, 23 were admitted. By applying ACEP level B recommendations to our population, all patients who on further workup were found to have cardiac syncope would have been admitted from the ED (100% sensitivity, 95% CI 86-100) and 81% of patients with no cardiac syncope would have been discharged from the ED (81% specificity, 95% CI 75-87). The admission rate would have been 28.5% (95% CI 22-35). By extending admission to patients satisfying level C in addition to level B recommendations, the sensitivity, specificity, and admission rate would have been 100% (95% CI 86-100), 33% (95% CI 26-40), and 71.0% (95% CI 64-77), respectively.

Conclusion

High sensitivity and specificity in identifying patients with cardiogenic syncope and significant reduction in the hospital admission rate were observed by applying ACEP level B recommendations to patients presenting to our ED. Application of level C recommendations did not offer any advantage.

Section snippets

Patient selection

All adult patients (aged 18 years or older) who presented to the ED at our tertiary-care teaching hospital between January 1996 and December 1998 were included in the study. Syncope was defined as sudden and temporary loss of consciousness and postural tone with spontaneous recovery.² Patients who required chemical or electrical cardioversion upon presentation were excluded. Also, patients were excluded if they had light-headedness, dizziness, vertigo, presyncope, coma, shock, spells, fall,

Demographics

From January 1996 to December 1998, 317 patients presented to the ED with a history of possible loss of consciousness. Of these, only 200 patients fulfilled the criteria of being 18 years or older and having had syncope. All patients enrolled in the study underwent an evaluation in the ED that consisted of history taking and physical examination. Of the total population, 115 patients were hospitalized and 85 were dismissed. The mean age (±SD) was 63 ± 20 years, 101 were men and 99 were women,

Main findings

In our ED, 58% of patients evaluated for syncope were admitted to the hospital for further inpatient evaluation and treatment. Of the total patients, 12% had cardiogenic causes of syncope. In our ED, the sensitivity for admitting patients with cardiogenic syncope was 96% (95% CI 79-100) and the specificity was 48% (95% CI 40-55). Under the ACEP level B guidelines, the sensitivity would have been 100% (95% CI 86-100) and the specificity would have been 81% (95% CI 75-87). Under the ACEP level C

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Cited by (47)

Application of Syncope Guidelines in the Emergency Department Do Not Reduce Admission Rates: A Retrospective Cohort Study
2018, Canadian Journal of Cardiology
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.
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.
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).
In conclusion, application of the current syncope guidelines to an emergency department population is unlikely to reduce low-risk hospital admissions.
La syncope à faible risque représente une forte proportion des hospitalisations, alors que des examens en milieu hospitalier ne sont souvent pas nécessaires et permettent rarement de formuler un diagnostic. La réduction du nombre d’admissions pour une syncope à faible risque pourrait vraisemblablement diminuer la consommation des ressources en santé et les dépenses globales. La mise en application par les urgentologues de lignes directrices concernant la syncope constitue une approche normalisée qui pourrait permettre de réduire le nombre d’admissions et donc, l’utilisation des ressources en soins de santé.
Une analyse rétrospective des dossiers médicaux de 1229 patients qui se sont présentés pour une syncope a été réalisée dans deux grands centres universitaires sur une période d’un an. Les lignes directrices et énoncés de position de trois grandes associations professionnelles ont été appliquées à ces cas pour en déterminer l’effet sur les taux d’admission.
Au total, 1031 patients ayant subi une syncope véritable ont été inclus dans l’analyse; 407 (39 %) de ces patients ont été hospitalisés et 624 (61 %) ont reçu leur congé du médecin traitant. On a observé un écart significatif entre les patients admis et les patients non admis (p < 0,01) quant à l’âge moyen [écart-type] (75 [14] vs 55 [22], respectivement) et la maladie cardiovasculaire au départ, y compris l’insuffisance cardiaque congestive (51/407 [13 %] vs 28/624 [5 %]), la coronaropathie (125/407 [31 %] vs 91/624 [15 %]) et la cardiopathie structurelle (36/407 [9 %] vs 26/624 [4 %]). Toutes les lignes directrices préconisaient l’admission de patients présentant un faible risque en plus grand nombre que les médecins traitants (19 %, comparativement à 34 % [p < 0,01] pour la Société canadienne de cardiologie, à 22 % [p = 0,03] pour l’American College of Emergency Physicians et à 26 % [p < 0,01] pour la Société européenne de cardiologie).
En conclusion, il est peu probable que la mise en application des lignes directrices actuelles sur le traitement des syncopes à l’égard de la clientèle des services d’urgence permette de réduire le nombre d’hospitalisations de patients présentant un faible risque.
Clinical Update on Nursing Home Medicine: 2016
2016, Journal of the American Medical Directors Association
Citation Excerpt :
Most persons with syncope do not need to be admitted to hospital. The guidelines for admission for syncope are congestive heart failure, hematocrit less than 30%, abnormal ejection fraction 9, dyspnea, or systolic blood pressure lower than 90 mm Hg.137 With the paucity of geriatricians and certified medical directors in the United States, it has become imperative to enhance the ability of primary care physicians to recognize and treat geriatric syndromes.
Mapping clinical journeys of Asian patients presenting to the Emergency Department with syncope: Strict adoption of international guidelines does not reduce hospitalisations
2016, International Journal of Cardiology
Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations.
Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1 year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated.
638 patients (43.8 ± 22.4 years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9 ± 3.2 days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p = 0.01) and prior hospitalization for syncope (HR 6.9, p < 0.01) predicted recurrent syncope. Over 2.8 SD 0.3 years of follow-up, 40 deaths occurred. 24 patients who died within 12 months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p = NS).
Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions.
Syncope units: Impact on patient care and health-related costs
2013, Cardiology Clinics
Citation Excerpt :
Syncope guidelines from the ESC6 and clinical policy and position statements from the ACEP,4 AHA/ACC Foundation,7 and American College of Physicians8,9 have made recommendations to risk stratify and systematize management of patients with syncope. Despite these published guidelines and position statements, hospitalization admission rates for patients presenting to EDs with recent syncope remain high, and the use of multiple testing continues to be frequent.10–12 The concept of an SMU in the ED (or in other inpatient or outpatient settings) originated from the question of whether a specialized unit designated for syncope evaluation could increase diagnostic outcomes and decrease hospital admission rates.
Syncope Management Unit: Evolution of the Concept and Practice Implementation
2013, Progress in Cardiovascular Diseases
Syncope, a clinical syndrome, has many potential causes. The prognosis of a patient experiencing syncope varies from benign outcome to increased risk of mortality or sudden death, determined by the etiology of syncope and the presence of underlying disease. Because a definitive diagnosis often cannot be established immediately, hospital admission is frequently recommended as the “default” approach to ensure patient's safety and an expedited evaluation. Hospital care is costly while no studies have shown that clinical outcomes are improved by the in-patient practice approach. The syncope unit is an evolving practice model based on the hypothesis that a multidisciplinary team of physicians and allied staff with expertise in syncope management, working together and equipped with standard clinical tools could improve clinical outcomes. Preliminary data have demonstrated that a specialized syncope unit can improve diagnosis in a timely manner, reduce hospital admission and decrease the use of unnecessary diagnostic tests. In this review, models of syncope units in the emergency department, hospital and outpatient clinics from different practices in different countries are discussed. Similarities and differences of these syncope units are compared. Outcomes and endpoints from these studies are summarized. Developing a syncope unit with a standardized protocol applicable to most practice settings would be an ultimate goal for clinicians and investigators who have interest, expertise, and commitment to improve care for this large patient population.
CT overuse for mild traumatic brain injury
2012, Joint Commission Journal on Quality and Patient Safety
Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations.
A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported.
All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60–0.70), ACEP 74.3% (95% CI, 0.70–0.79), NICE 86.7% (95% CI, 0.83–0.90), and NOC 90.5% (95% CI, 0.87–0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported.
Some 10%–35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.

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Clinical InvestigationImpact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department

Background

Methods

Results

Conclusion

Section snippets

Patient selection

Demographics

Main findings

Am. J. Med.

Ann. Emerg. Med.

Ann. Emerg. Med.

J. Am. Coll. Cardiol.

Am. Heart. J.

A prospective evaluation and follow-up of patients with syncope

N. Engl. J. Med.

Evaluation and outcome of patients with syncope

Medicine (Baltimore)

Patients with syncope admitted to medical intensive care units

JAMA

Diagnosis of patients with syncope in emergency medicine

Keio J. Med.

Clinical policy: critical issues in the evaluation and management of patients presenting with syncope

Ann. Emerg. Med.

Sinus node dysfunction: pathophysiology, clinical features, evaluation, and treatment

Clinical Investigation
Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department