title: Assessment of a structured management pathway for patients referred to the Emergency Department for syncope: results in a tertiary hospital.
abstract: OBJECTIVE
  High hospitalization rates (39-58% in the literature) of patients admitted to Emergency Department (ED) for transient loss of consciousness (T-LOC) suspected for syncope are still an unresolved issue. The presence of an Observation Unit has reduced hospital admissions and the duration of hospitalization in controlled studies, and a Syncope Unit (SU) in the hospital may reduce hospitalization and increase the number of diagnoses in patients with T-LOC. We assessed the effect of a structured organization on hospitalization rate and outcome.
  
  
  RESULTS
  Consecutive patients referred to the ED for a T-LOC of a suspected syncopal nature as the main diagnosis were included. The ED physician was trained to choose between: hospital admission (directly or after short observation); discharge after short (<48-h) observation; discharge on a fast track to the SU; and direct discharge without any further diagnostics. From January to June 2010, 362 patients were evaluated in the ED: 29% were admitted, 20% underwent short observation in the ED, 20% were referred to the SU, and 31% were directly discharged. Follow-up data were available on 295 patients who were discharged alive: of these, 1 (0.3%) previously hospitalized patient died within 30 days and 16 (5.4%) died within 1 year. Death rates were 12.9, 3.3, 0, and 2.5% among admitted, observation, SU, and ED-discharged patients, respectively. No death could be directly attributed to T-LOC. Re-admission within 1 year for any cause occurred in 72 (24%) patients; re-admission rates were 45.9, 19.3, 11.5, and 18.0% among admitted, observation, SU, and ED-discharged patients, respectively.
  
  
  CONCLUSIONS
  The availability of short observation and a SU seems to reduce the hospitalization rate compared with previous reported historical reports from our and other centres. Most deaths during follow-up occurred in patients who had been hospitalized. High rates of re-admission to the ED within 1 year are still an issue.
authors.affiliation: Syncope Unit, Unit of Geriatric Cardiology and Medicine, Department of Experimental and Clinical Medicine, Careggi Hospital and University of Florence, Viale Pieraccini 6, Florence 50141, Italy aungar@unifi.it.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ungar
authors.affiliation: Syncope Unit, Unit of Geriatric Cardiology and Medicine, Department of Experimental and Clinical Medicine, Careggi Hospital and University of Florence, Viale Pieraccini 6, Florence 50141, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Tesi
authors.affiliation: Syncope Unit, Unit of Geriatric Cardiology and Medicine, Department of Experimental and Clinical Medicine, Careggi Hospital and University of Florence, Viale Pieraccini 6, Florence 50141, Italy.
authors.forename: Valentina Maddalena
authors.initials: VM
authors.lastname: Chisciotti
authors.affiliation: Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Pepe
authors.affiliation: Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Vanni
authors.affiliation: Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Grifoni
authors.affiliation: Epidemiology Unit, Local Health 10, Florence, Italy.
authors.forename: Daniela
authors.initials: D
authors.lastname: Balzi
authors.affiliation: Syncope Unit, Unit of Geriatric Cardiology and Medicine, Department of Experimental and Clinical Medicine, Careggi Hospital and University of Florence, Viale Pieraccini 6, Florence 50141, Italy.
authors.forename: Martina
authors.initials: M
authors.lastname: Rafanelli
authors.affiliation: Syncope Unit, Unit of Geriatric Cardiology and Medicine, Department of Experimental and Clinical Medicine, Careggi Hospital and University of Florence, Viale Pieraccini 6, Florence 50141, Italy.
authors.forename: Niccolò
authors.initials: N
authors.lastname: Marchionni
authors.affiliation: Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Brignole
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006757:Hospital Units / Q000458:organization & administration*; D006801:Humans; D007558:Italy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D019370:Observation; D010343:Patient Admission; D010351:Patient Discharge; D011379:Prognosis; D015397:Program Evaluation; D012017:Referral and Consultation / Q000458:organization & administration*; D013575:Syncope / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D062606:Tertiary Care Centers / Q000458:organization & administration*; D013997:Time Factors; D055815:Young Adult
keywords: Emergency department; Pathways; Syncope; Syncope Unit