Background: There are more than 1.2 million annual emergency department (ED) visits for syncope in the United States. Prior studies have demonstrated that many associated admissions and diagnostic studies, including echocardiogram, carotid ultrasound and head computed tomography (CT), may be unnecessary. Our objective was to determine the effectiveness of a novel protocol for syncope care in the ED in reducing unnecessary admissions and diagnostic testing.
Methods: A multi-disciplinary team, including members from cardiology, emergency medicine and hospital medicine, developed a decision aid for ED syncope management. (Figure 1) The decision aid utilized best available evidence to syncope management, including specific indications for diagnostic testing and hospital admission. The new protocol was disseminated among ED staff via email and presentations at resident and faculty meetings. It was also integrated into the syncope “Smartphrase” templates in the electronic medical record (EMR), and feedback on usage rates of the EMR template at the individual provider level was shared at regular intervals. Patients considered safe for discharge were provided expedited appointments in a previously established syncope specialty clinic. The new syncope protocol was implemented in January 2020. The effectiveness of the new process was assessed by measuring rates of admission, utilization of diagnostic studies (head CT, carotid ultrasound, echocardiogram) and rates of 30-day ED revisits before and after implementation.
Results: We identified 308 ED patients with syncope before (September 2019 thru December 2019) and 321 after (January 2020 thru June 2020) protocol implementation. The proportion of patients with syncope who were admitted decreased significantly (44.6% to 30.0%, p<0.001. Figure 2), while the proportion undergoing diagnostic studies was unchanged (19.5% to 16.0%, p=0.303). The proportion with 30-day ED revisits was also unchanged (11.2% to 10.2%, p=0.769). The proportion referred for expedited follow up to a syncope specialty clinic increased (1.5% to 8.8%, p<0.001).
Conclusions: Implementation of an syncope care pathway for patients in the ED, including a process for referral to a syncope specialty clinic, was associated with significantly reduced hospital admissions. Utilization of diagnostic testing and rates of 30-day ED revisits were unchanged. Additional studies to evaluate the scalability and cost benefits of this program are warranted but wider dissemination of similar models could potentially offer substantial reduction in unnecessary healthcare utilization.
