Background: Syncope is a common diagnosis for hospitalists and often accompanied by extensive and unnecessary diagnostic workup. Neurally-mediated syncope and orthostatic hypotension account for over 75% of causes. Most causes of syncope can be diagnosed with a good history and physical.  Unfortunately, costly and harmful testing such as head CTs are ordered, while simple and harmless diagnostic tests like orthostatic vital signs are omitted. We reviewed patients admitted to the observation unit for syncope and collapse to investigate the workup, appropriateness, and diagnostic yield. 

Methods: We performed a retrospective chart review over a four-month period (10/2014 – 1/2015) of patients admitted to the observation unit of an urban tertiary care center in New York City with the ICD-9 DRG of “symptom, syncope and collapse.” All patients followed the syncope observation unit protocol: cardiac, vascular, and neurologic exam; ECG, CBC, electrolytes, glucose; pregnancy test if female, minimum of 12 hours of continuous telemetry monitoring; electrophysiology consult if high risk ECG; transthoracic echocardiogram (TTE) if new murmur appreciated. For each patient encounter, documentation and testing were abstracted from the electronic record. We used the American College of Emergency Physicians (ACEP) Choosing Wisely® recommendation to avoid CT head in asymptomatic adult patients with syncope, insignificant trauma, and a normal neurological evaluation to determine the appropriateness of each head CT ordered.

Results: 60 patient encounters were reviewed. The age range was 23 to 93 with mean age 66. The most common comorbidities in the group were hypertension (37%), previous syncopal episode(s) (35%), diabetes (30%), arrhythmia (15%), seizure history (8.3%), and valvular abnormality (8.3%). Thirty-eight patients actually lost consciousness (63%), whereas 18 patients experienced presyncope (30%), and in 4 cases it could not be ascertained because the episode was unwitnessed in patients with dementia. Cause of syncope was documented as neurally-mediated in 10 cases (17%), cardiac in 2 (3%), seizure in 3 (5%), alcohol/medication-induced in 7 (12%), and never definitively established in 38 (63%). Orthostatic blood pressure measurements were not documented in 54 patients (90%). Orthostatics were documented as “positive,” “negative,” or “done” in 5 patients (8%). Exact numeric orthostatics were documented for only 1 patient. Twenty-three patients received a CT head (48%). Of those scans, nine were inappropriate (39%) according to the ACEP Choosing Wisely® recommendation. Fifteen percent of the 60 patients received an unnecessary head CT. None of the CTs showed acute changes, such as hemorrhage, that would have changed medical management. Of the 23 scans performed, five scans had incidental findings, such as an arachnoid cyst or frontal hygroma (8%). Six patients underwent TTEs (8.3%); one patient underwent a stress test.

Conclusions: For the vast majority of patients admitted to the observation unit for syncope, orthostatics were not documented, but head CTs were ordered for nearly half of patients, of which 39% were inappropriate.  Our aim is to appropriately identify patients who benefit from prompt management for orthostatic hypotension and in which head CTs are unnecessary.  We anticipate devising an intervention to integrate orthostatics into the observation unit workflow.