title: Reducing admissions utilizing the Boston Syncope Criteria.
abstract: 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%.
  
  
  CONCLUSIONS
  In our ED, implementing the Boston Syncope Criteria safely reduced admissions to the hospital. Future studies are needed to test external validity and generalizability.
authors.affiliation: Division of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02115, USA.
authors.forename: Shamai A
authors.initials: SA
authors.lastname: Grossman
authors.forename: Jessica
authors.initials: J
authors.lastname: Bar
authors.forename: Christopher
authors.initials: C
authors.lastname: Fischer
authors.forename: Lewis A
authors.initials: LA
authors.lastname: Lipsitz
authors.forename: Lawrence
authors.initials: L
authors.lastname: Mottley
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sands
authors.forename: Peter
authors.initials: P
authors.lastname: Zimetbaum
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D013575:Syncope / Q000209:etiology*