Applying the Boston syncope criteria to near syncope.

BACKGROUND: We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well. OBJECTIVE: To determine if BSC accurately predict which near-syncope patients require hospitalization. METHODS: A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls. RESULTS: Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up. CONCLUSION: Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.

Sustained effectiveness of a primary-team-based rapid response system.

OBJECTIVE: Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient's usual care providers, not a critical-care-trained rapid-response team, would improve patient outcomes. DESIGN, SETTING, AND PATIENTS: An interrupted time-series analysis of over a 59-month period. SETTING: Urban, academic hospital. PATIENTS: One hundred seven-one thousand, three hundred forty-one consecutive adult admissions. INTERVENTION: In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient's existing care providers was assembled. MEASUREMENTS AND MAIN RESULTS: The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%-83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%-89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82-1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2). CONCLUSIONS: A primary-team-based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient's usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.

Reducing admissions utilizing the Boston Syncope Criteria.

BACKGROUND: We previously developed criteria to identify patients with syncope at risk for adverse events. Although we proposed a theoretical substantial reduction in admission, these criteria were untested in actual practice. OBJECTIVE: To perform a prospective effectiveness study testing the hypothesis that using the Boston Syncope Criteria as a clinical guideline will safely reduce the proportion of patients admitted with syncope. METHODS: A prospective, before-and-after cohort study of consecutive Emergency Department (ED) patients presenting with syncope. After in-service training, the Boston Syncope Criteria were implemented as a clinical guideline for emergency physicians who were encouraged to make admission decisions based on the criteria adverse outcomes at 30-day follow-up, including death, myocardial infarction/intervention, dysrhythmia or alterations in dysrhythmics, pulmonary embolus, stroke, or hemorrhage. Operating characteristics of the rule and 95% confidence intervals (CI) were calculated. RESULTS: In the "before" phase, 201/293 (69%; 95% CI 63-74%) patients with syncope were admitted, compared to 160/277 (58%; 95% CI 52-64%) after the criteria were introduced; an 11% reduction in admission. Among the 160 patients admitted after the intervention, 64 (40%) had adverse events during hospitalization, compared to none in the discharged group. At 30-day follow-up, 6 additional patients (4%) had adverse outcomes; all were admitted initially. Real-time application of the criteria had a sensitivity of 100% (95% CI 94-100%), a specificity of 57% (95% CI 50-63%), and a negative predictive value of 100%. CONCLUSION: In our ED, implementing the Boston Syncope Criteria safely reduced admissions to the hospital. Future studies are needed to test external validity and generalizability.

Do outcomes of near syncope parallel syncope?

BACKGROUND: Limited information on the evaluation of emergency department (ED) patients complaining of "near syncope" exists. Multiple studies of syncope exclude near syncope claiming near syncope is poorly defined and its definition is nonuniform. OBJECTIVE: The aim of this study was to determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope. METHODS: Prospective, observational study enrolling (August 2007-October 2008) consecutive ED patients (age, ≥18 years) presenting with near syncope was conducted. Near syncope was defined as an episode in which the patient felt they might lose consciousness but did not. Critical intervention/adverse outcome was defined as hemorrhage, cardiac ischemia/intervention, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, dysrhythmia, sepsis, pulmonary embolus, or carotid stenosis. Primary outcome was an adverse outcome or critical intervention in hospital or less than 30 days. Near syncope and syncope outcomes and admission rates were compared using the χ(2) test. RESULTS: After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001). CONCLUSION: Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted. Given similar risk of adverse outcomes for near syncope and syncope, future studies are warranted to improve the treatment of ED patients with near syncope.

Emergency department abnormal vital sign "triggers" program improves time to therapy.

BACKGROUND: Implementation of rapid response systems to identify deteriorating patients in the inpatient setting has demonstrated improved patient outcomes. A "trigger" system using vital sign abnormalities to initiate evaluation by physician was recently described as an effective rapid response method. OBJECTIVES: The objective was to evaluate the effect of a triage-based trigger system on the primary outcome of time to physician evaluation and the secondary outcomes of therapeutic intervention, antibiotics, and disposition in emergency department (ED) patients. METHODS: A separate-samples pre- and postintervention study was conducted using retrospective chart review of outcomes in ED patients for three arbitrarily selected 5-day periods in 2007 (pretriggers) and 2008 (posttriggers). There were 2,165 and 2,212 charts in the pre- and posttriggers chart review, with 71 and 79 patients meeting trigger criteria. Trigger criteria used to identify patients at triage were: heart rate of <40 or >130 beats/min, respiratory rate of <8 or >30 breaths/min, systolic blood pressure of <90 mm Hg, and oxygen saturation of <90% on room air. Median times (in minutes) were compared between pre- and posttrigger groups with interquartile ranges (IQRs 25-75), with the Wilcoxon rank sum test used to determine statistical significance. RESULTS: Overall median times were decreased among the posttriggers group. Median times to physician evaluation (21 minutes [IQR = 13-41 minutes] vs. 11 minutes [IQR = 5-21 minutes]; p < 0.001), first intervention (58 minutes [IQR = 20-139 minutes] vs. 26 minutes [IQR = 11-71 minutes]; p < 0.01), and antibiotics (110 minutes [IQR = 74-171 minutes] vs. 69 minutes [IQR = 23-130 minutes]; p < 0.01) were significant. Median times to disposition (177 minutes [IQR = 121-303 minutes] vs. 162 minutes [IQR = 114-230 minutes]; p = 0.18) were not significant. CONCLUSIONS: Implementation of an ED triggers program allows for more rapid time to physician evaluation, therapeutic intervention, and antibiotics.

Can benign etiologies predict benign outcomes in high-risk syncope patients?

BACKGROUND: We previously studied and validated risk factors for adverse outcomes or need for critical intervention in syncope. OBJECTIVE: To determine whether high-risk patients, diagnosed with benign etiologies of syncope after a normal emergency department (ED) work-up, sustain favorable outcomes. METHODS: Prospective, observational cohort of consecutive ED patients aged ≥ 18 years with syncope. Benign etiology was defined as vasovagal syncope or dehydration. Patients were followed up to 30 days to identify adverse outcomes including death, myocardial infarction, dysrhythmia, alterations in antidysrhythmics, percutaneous intervention, pulmonary embolus, stroke, metabolic catastrophe, or significant hemorrhage. RESULTS: Patients presented with benign etiologies in 164/293, 56% (95% confidence interval [CI] 50-62%) of cases. Of these, pathologic conditions were identified during ED evaluation in 11/164, 7% (95% CI 3-11%) of cases. This includes ED findings/treatments of blood transfusion, severe electrolyte disturbance, incarcerated hernia, rhabdomyolysis, subarachnoid hemorrhage, bowel obstruction, dysrhythmia, and transient ischemic attack. The remaining 153 with benign presentations had no adverse outcomes at 30 days, while 57/129 (44%) patients with non-benign etiologies had adverse outcomes in the hospital or within 30 days. Previously, we demonstrated a 48% reduction in admission rate if only patients with risk factors for adverse outcome were admitted. If patients with both benign etiologies and a negative ED work-up were sent home, even if they had risk factors for an adverse outcome, an additional 19% (95% CI 14-25%) reduction in hospital admissions would have occurred. CONCLUSIONS: In patients with presentations consistent with a benign etiology of syncope (vasovagal or dehydration) where the ED work-up was normal, we found no patients who would benefit from hospitalization based on risk factors alone.

Predicting adverse outcomes in syncope.

Syncope is a common presentation to the Emergency Department (ED); however, appropriate management and indications for hospitalization remain an ongoing challenge. The objective of this study was to determine if a predefined decision rule could accurately identify patients with syncope likely to have an adverse outcome or critical intervention. A prospective, observational, cohort study was conducted of consecutive ED patients aged 18 years or older presenting with syncope. A clinical decision rule was developed a priori to identify patients at risk if they met any of the following 8 criteria: 1) Signs and symptoms of acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical examination; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion; 8) Primary central nervous system event. The primary outcome was either a critical intervention or an adverse outcome within 30 days. Among 362 patients enrolled with syncope, 293 (81%) patients completed their 30-day follow-up. Of these, 201 (69%) were admitted. There were 68 patients (23%) who had either a critical intervention or adverse outcome. The rule identified 66/68 patients who met the outcome for a sensitivity of 97% (95% confidence interval 93-100%) and specificity of 62% (56-69%). This pathway may be useful in identifying patients with syncope who are likely to have adverse outcome or critical interventions. Implementation and multicenter validation is needed before widespread application.