The number of hospitals with dedicated observation units has grown in recent years to one-third of all United States hospitals and 80% of academic medical centers, though much is still unknown about how to best deliver care in this setting. At our institution, syncope is among the most common indications for admission to the observation unit. The most recent society guidelines for syncope management are from the European Society of Cardiology (ESC) and suggest that patients presenting with syncope with certain high-risk features be monitored on telemetry. We sought to determine whether patients admitted with syncope to our observation unit for telemetry monitoring met these criteria, and how often the results from telemetry had a meaningful impact on their care, with the goal of determining whether we are using this resource effectively.
We performed a retrospective analysis of all patients admitted to the observation unit in our tertiary-care center for telemetry monitoring with a diagnosis of syncope or near syncope from September to November, 2015. A physician reviewed each chart and assessed whether the patients had one of the guideline-based high-risk features that are indications for telemetry monitoring. We also evaluated whether any telemetry events were observed, whether these events ultimately changed patient management, and if so, in what way.
There were 47 patients admitted during the study period with a diagnosis of syncope (n= 39) or near syncope (n=8). Of these, 17 (36%) had a high-risk feature that was an indication for telemetry monitoring based on the ESC guidelines. Average length of stay in the observation unit was 18 hours. Two (4%) of the patients had events on telemetry during their observation stay. One had sinus bradycardia but was later diagnosed with a seizure disorder that was thought to have caused their presentation. He underwent an outpatient echocardiogram that was unrevealing. The other patient initially had sinus bradycardia and later developed PEA arrest. The patient was DNR/DNI and expired without medical intervention. None of the patients derived a clinical benefit from telemetry monitoring.
Of the patients sent to the observation unit with a diagnosis of syncope or near syncope, most did not meet guideline criteria for telemetry monitoring. Additionally, none of the patients had a meaningful change in their management based on the telemetry findings while in the observation unit. Both emergency department and observation unit providers should be cognizant of whether patients without high-risk features require observation admission for syncope. Additionally, given the low yield of telemetry in this series and the absence of any clinical benefit, further review is needed to determine which patients would be more likely to benefit from telemetry monitoring in an observation unit.