Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission.
OBJECTIVE
Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.


METHODS
This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.


RESULTS
Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.


CONCLUSIONS
An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.
Department of Emergency Medicine, Oregon Health and Science University, Portland, OR. Electronic address: sunb@ohsu.edu.
Benjamin C
BC
Sun
Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Heather
H
McCreath
Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Li-Jung
LJ
Liang
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
Stephen
S
Bohan
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
Christopher
C
Baugh
Department of Emergency Medicine, Duke University Medical Center, Durham, NC.
Luna
L
Ragsdale
Department of Emergency Medicine, University of Southern California, Los Angeles, CA.
Sean O
SO
Henderson
Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI.
Carol
C
Clark
Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI.
Aveh
A
Bastani
RAND Corporation, Santa Monica, CA.
Emmett
E
Keeler
College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL.
Ruopeng
R
An
Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA.
Carol M
CM
Mangione
D000368:Aged; D002985:Clinical Protocols; D004636:Emergency Service, Hospital; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D063868:Patient Outcome Assessment; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011788:Quality of Life; D013575:Syncope / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D057832:Watchful Waiting / Q000379:methods*