Emerg Med J 2010;27:870-872 doi:10.1136/emj.2010.092924
- Short report
The inpatient management of syncope
+ Author Affiliations
- Correspondence to Matthew J Reed, Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK; matthew.reed@luht.scot.nhs.uk
- Contributors LT and MJR were involved in all stages of the study.
- Accepted 10 May 2010
- Published Online First 3 August 2010
Abstract
Introduction The management and risk stratification of patients with syncope in the Emergency Department (ED) has been the emphasis of much recent research, however little is known about inpatient management especially in the UK. The aim of this study was to examine the inpatient management of patients with syncope admitted to hospital from a UK ED.
Methods This was a single centre prospective observational cohort study, recruiting patients with syncope admitted to hospital from a UK ED. Inpatient management was examined focusing on length of stay and investigations undertaken.
Results Between 3 March 2007 and 22 July 2008, 540 patients presenting with syncope to the ED of the Royal Infirmary of Edinburgh, UK were admitted and enrolled. Median and mean length of stay was 1 day (IQR 1–4) and 6.3 days (SD 15.5). In all, 392 (73%) patients were admitted to General/Acute Medicine, 39 (7%) to Cardiology, 35 (7%) to Medicine of the Elderly, 33 (6%) to surgical specialities and the rest to other specialities. A diagnosis was finally made in 342 (63%) patients including 33 (85%) of the 39 admitted to Cardiology and 239 (61%) of the 392 patients admitted to General/Acute Medicine. The use of diagnostic tests varied between specialities with more intensive investigation undertaken in patients admitted to Cardiology.
Conclusions The current approach to the inpatient management of syncope is speciality dependent. Standardised diagnostic pathways may improve diagnostic yield and cost effectiveness.
Introduction
The hospital management of syncope incurs a considerable cost burden, estimated to be around £611 per patient.1 The majority of this is accounted for by the hospital stay, estimated to be £1080 per diagnosis.1 The European Society of Cardiology (ESC) has published guidelines to aid diagnosis and management of syncope,2 involving initial evaluation with thorough history taking and physical examination, followed by risk stratification to identify high-risk patients with a potential underlying cardiac cause warranting hospital admission and further investigation. Studies suggest that following hospital admission, concerns about serious underlying causes often result in the use of extensive investigations, which may be considered unnecessary and cost ineffective.3 The aims of this study were to examine the inpatient management of admitted patients with syncope, focusing on length of hospital stay and investigations undertaken.
Methods
Design and setting
This was a single centre prospective observational cohort study looking at the inpatient management of admitted ROSE (for ‘Risk stratification Of Syncope in the Emergency department’) study patients.4 The study was conducted in the Royal Infirmary of Edinburgh, a major acute teaching hospital with over 900 inpatient beds and 110 000 adult attendances per year to the ED.
Study population
Adult patients (≥16) admitted to hospital after presenting to the ED with syncope were enrolled. For inclusion and exclusion criteria see the ROSE study.4 The decision to admit, usually for investigation of or as a consequent of syncope, and referral speciality was made by the attending clinician. Usually only patients at high risk of a cardiology cause are routinely accepted by inpatient cardiology. Investigations were arranged at the discretion of the treating doctor and not algorithm based.
Outcome measures
The following information was collected: length of admission, admitting speciality, admission to a monitored bed, cardiology consultation, use of echocardiogram, 24 h electrocardiogram (ECG) tape, exercise tolerance testing (ETT), tilt table testing, carotid sinus massage (CSM), postural blood pressure (PBP), angiography or pacemaker insertion. Additionally, information was gathered regarding investigations in the preceding 2 years, as further investigation may not have been considered necessary if previously investigated.
Methodology
Electronic patient records (EPR) were accessed. The index episode was identified and data was collected, recorded and analysed using Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA). Separate databases in all regional hospitals were also consulted.
Results
Study population
Between 3 March 2007 and 22 July 2008, 540 patients were admitted and enrolled; 259 (48%) were men and 281 (52%) were women. The mean age was 73 (SD 15.5) years.
Details of admission
The median and mean length of stay was 1 day (IQR 1–4) and 6.3 days (SD 15.5) (figure 1). A total of 392 patients were admitted to General/Acute Medicine (72.6%), 39 to Cardiology (7.2%), 35 to Medicine of the Elderly (6.5%), 33 to surgical specialities (6.1%), 20 to medical specialities (3.7%) and 21 (3.9%) to other inpatient specialities; 85 patients (15.7%) were seen by a cardiologist during admission or as an outpatient, and 142 patients (26.3%) were admitted to a monitored bed from the ED.
Figure 1
Histogram showing length of admission stay.
Investigations
In all, 139 patients (25.7%) had no further cardiological investigations performed after admission and 323 (59.8%) patients had erect and supine blood pressures performed. A total of 117 (21.7%) patients were, or had previously been investigated with echocardiography, 158 (29.3%) underwent 24 h ECG recording and 27 (5%) patients underwent ETT. A total of 16 patients (2.9%) underwent tilt table testing, 5 prior to their index collapse. In all, 3 patients underwent CSM during their admission, while a further 18 were investigated later in the outpatient clinic (total 3.9%). At presentation, 29 patients (5.4%) already had a pacemaker and 19 (3.5%) further patients were subsequently fitted with a device. A total of 16 patients (2.9%) had angiography and 1 patient underwent a cardiac MRI scan.
Diagnosis
The underlying cause of syncope was identified in 342 (62.8%) patients, including 33 (85%) of the 39 admitted to Cardiology and 239 (61%) of the 392 patients admitted to General/Acute Medicine. The underlying cause was ‘neurally mediated’ in 87 (25%), ‘cardiac’ in 78 (23%), ‘orthostatic hypotension’ in 102 (30%) and ‘other’ in 75 (22%). ‘Other’ causes were many and varied. Of the 78 patients identified as having an underlying cardiac cause, 36 (46.2%) underwent echocardiography, 38 (35.9%) had 24 h ECG recording and 5 (6.4%) underwent ETT. The use of investigations varied between specialities (table 1).
View this table:
Table 1
Number and percentage of patients admitted to Cardiology and General/Acute Medicine departments who underwent each investigation
Discussion
This study suggests that the inpatient management of syncope varies depending on the admitting speciality and use of cardiology investigations is limited. These findings are supported by Blanc et al, who found considerable differences in syncope management across specialities.5 84.6% of patients admitted to Cardiology were given a definitive diagnosis compared to 61.2% admitted to Medicine. Overall, the underlying cause for syncope was identified in 62.8% of patients, similar to other studies.6 7
A 1-day median length of stay in our study suggests an ED observation unit/Clinical Decision Unit may have a potential role. The Syncope Evaluation in the Emergency Department Study (SEEDS) group proposed the use of a syncope observational unit in the ED and a multidisciplinary approach.8 Following standard initial evaluation, patients underwent 6 h of cardiac telemetry, hourly vital signs and PBP checks in addition to selective echocardiography. Additional investigations (ie, tilt table testing and CSM) and admission/outpatient referral were then arranged by the ED doctor as required. This approach improved diagnostic yield, reduced admissions and improved long-term outcome.8 Use of a standardised care pathway was also found to be beneficial by Brignole et al, resulting in a considerable improvement in diagnostic yield and cost per reliable diagnosis.9
There are limitations to this study. It is only reporting on the practice in one centre. We were also unable to measure the diagnostic yield, cost effectiveness and relative merit of each test. Differences in management, level of investigation and diagnostic success may reflect speciality referral patterns and differences in patient groups.
In conclusion, the findings of this study suggest that the current inpatient management of syncope may be suboptimal and speciality dependant. Many patients are discharged without diagnosis and undergo different levels of investigation. While progress is being made in risk stratification and reducing unnecessary admissions, there is a need to identify a simple, targeted approach to investigation and inpatient management using clear and concise guidelines, regardless of admitting speciality. Potential solutions have been suggested, ranging from diagnostic algorithms to specialised syncope facilities. Perhaps the next step could be to combine the recently developed ROSE CDR for risk stratification with a short stay clinical decision unit using standardised care pathways followed by more standardised inpatient management advocated in previous studies and by ESC guidelines.2
Acknowledgments
We thank the staff in the Emergency Department of the Royal Infirmary of Edinburgh for their help with patient recruitment for this study, Mags Pryde at the Royal Infirmary of Edinburgh and Martin Hayes at the Western General Hospital for their help with cardiology investigations, and Dr Andrew McIntosh for his assistance in obtaining data relating to CSM and tilt table testing.
Footnotes
- Funding MR received funding from a Chief Scientist Office research fellowship (CSO/CAF/06/01). The sponsor of the study had no role in study design, data collection, data management, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and has final responsibility for the decision to submit for publication.
- Competing interests None.
- Ethics approval This study was granted ethical approval by the Multi-Centre Research Ethics Committee for Scotland A (06/MRE00/107) and the Lothian Regional Ethical Committee (06/S11ADMIN/151).
- Provenance and peer review Not commissioned; externally peer reviewed.
References
- Moya A,Sutton R,Ammirati F et al
- Del Greco MCS,Scillieri M,Caprari Fet al
- Reed MJ,Newby DE,Coull AJ et al
- Blanc JJ, L'Her C, Touiza A,et al
- Shen WK,Decker WW,Smars PA,et al Syncope Evaluation in the Emergency Departments (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004;110:3636–45.
- Brignole M,Ungar A, Bartoletti A et al
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