title: Mapping clinical journeys of Asian patients presenting to the Emergency Department with syncope: Strict adoption of international guidelines does not reduce hospitalisations.
abstract: BACKGROUND
  Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations.
  
  
  METHODS
  Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated.
  
  
  RESULTS
  638 patients (43.8±22.4years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9±3.2days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p=0.01) and prior hospitalization for syncope (HR 6.9, p<0.01) predicted recurrent syncope. Over 2.8 SD 0.3years of follow-up, 40 deaths occurred. 24 patients who died within 12months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p=NS).
  
  
  CONCLUSIONS
  Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions.
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore. Electronic address: pipin_kojodjojo@nuhs.edu.sg.
authors.forename: Pipin
authors.initials: P
authors.lastname: Kojodjojo
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Elaine
authors.initials: E
authors.lastname: Boey
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Anita
authors.initials: A
authors.lastname: Elangovan
authors.affiliation: Department of Emergency Medicine, National University Hospital, Singapore.
authors.forename: Xianyi
authors.initials: X
authors.lastname: Chen
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Yuquan
authors.initials: Y
authors.lastname: Tan
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Devinder
authors.initials: D
authors.lastname: Singh
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Wee Tiong
authors.initials: WT
authors.lastname: Yeo
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Toon Wei
authors.initials: TW
authors.lastname: Lim
authors.affiliation: Department of Cardiology, National University Heart Centre, National University Hospital, Singapore.
authors.forename: Swee Chong
authors.initials: SC
authors.lastname: Seow
authors.affiliation: Department of Emergency Medicine, National University Hospital, Singapore.
authors.forename: Tiong Beng
authors.initials: TB
authors.lastname: Sim
mesh_terms: D000328:Adult; D000368:Aged; D001208:Asia; D019468:Disease Management; D004636:Emergency Service, Hospital; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D013575:Syncope / Q000453:epidemiology* / Q000628:therapy*; D055815:Young Adult
keywords: Asian; Guidelines; Outcomes; Syncope