Hospital Admission and Diagnostic Tests Are Overused in Patients Presenting to the Emergengy Department with Syncope

1University of California San Diego Health System, San Diego, CA
2UNIVERSITY OF CALIFORNIA SAN DIEGO, SAN DIEGO, CA
3UNIVERSITY OF CALIFORNIA LOS ANGELES, Santa Monica, CA
4UC San Diego Medical Center, San Diego, CA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 131

Background:

The evaluation of syncope remains challenging, costly, and in many instances, does not clarify the etiology. Evidence‐based guidance for efficient evaluation and risk stratification is often not followed. We designed a study to assess our current evaluation of syncope compared to a best‐practice evaluation protocol, and to confirm the utility and safety of an evaluation algorithm.

Methods:

A multidisciplinary group developed a protocol for the evaluation of syncope based on literature and guideline review. A retrospective chart review was performed for patients that were evaluated for syncope in the Emergency Department of our acute care university medical center, from April to June, 2011.Patient demographics, vital signs, and tests performed or recommended for patients with syncope were recorded and analyzed for their appropriateness per protocol, and influence on diagnosis and management. Adverse outcomes (ICU admission, blood transfusions, cardiac catheterization, pacemaker or AICD placement, readmission to Emergency department or death within 30 days) were tracked. Emergency and Internal Medicine physician abstractors independently reviewed each chart, with discussion and adjudication of all discrepancies prior to data entry.

Results:

138 syncope cases were confirmed after excluding 45 patients who did not meet diagnostic criteria for syncope. History data important for risk stratification were not obtained or documented for many patients (history of myocardial infarction not documented in 65 patients, Congestive heart failure 45, preceding palpitations 43). Orthostatic vital signs were performed in only 25% of patients. 61 patients were high and 77 low‐ risk, based on a risk stratification tool included in the protocol. A high number of hospital admissions (10) and tests (26 Troponin measurements, 22 ECG monitoring, 10 Echocardiograms, 19 CT head, 2 MRIs brain, 5 Carotid US, 1 EEG) were performed outside of algorithm guidance and deemed potentially unnecessary. The few adverse outcomes were limited to high risk patients. Trained reviewers using the algorithm had a better diagnostic accuracy than providers during the index evaluation.

Conclusions:

Syncope evaluation and management often varied from a best‐practice evaluation protocol. The evidence‐based evaluation algorithm incorporating history, physical examination, and simple tests (orthostatic vital signs, electrocardiogram, and hemoglobin) appeared safe, while having the capacity to increase diagnostic accuracy and reduce resource utilization. Extensive, but focused, testing and hospital admission should be reserved for high‐risk patients. Syncope evaluation is a major opportunity to improve the quality and efficiency of healthcare.

To cite this abstract:

Popa R, Oyama L, Tolia V, Lee E, Kelly C, Castillo E, Maynard G. Hospital Admission and Diagnostic Tests Are Overused in Patients Presenting to the Emergengy Department with Syncope. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 131. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/hospital-admission-and-diagnostic-tests-are-overused-in-patients-presenting-to-the-emergengy-department-with-syncope/. Accessed November 17, 2019.

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