Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis

This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy

Management of transient loss of consciousness of suspected syncopal cause, after the initial evaluation in the Emergency Department

The recommendations enclosed in the present document have been developed by a group of experts appointed by the Gruppo Multidisciplinare per lo Studio della Sincope (Multidisciplinary Group for the Study of Syncope; GIMSI) and Academy of Emergency Medicine and Care (AcEMC). The aim is to define the diagnostic pathway and the management of patients referred to the Emergency Department (ED) for transient loss of consciousness of suspected syncopal cause, which is still unexplained after the initial evaluation. The risk stratification enables the physician to admit, discharge or monitor shortly the patient in the intensive short-stay Syncope Observation Unit (SOU). There are three risk levels of life-threatening events or serious complications (low, moderate, high). Low risk patients can be discharged, while high risk ones should be monitored and treated properly in case of worsening. Moderate risk patients should undergo clinical and instrumental monitoring in SOU, inside the ED. In all these three cases, patients can be subsequently referred to the Syncope Unit for further diagnostic investigations

Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial

Analysis of Temporal and Causal Relationship Between Syncope and 30-Day Events in a Cohort of Emergency Department Patients to Identify the True Rate of Short-term Outcomes

BACKGROUND: There are a limited number of studies on the short-term prognosis of syncopal patients, and those available are heterogeneous and often have considered events without a clear relationship with the syncopal episode as serious outcomes. OBJECTIVE: The aim of this study was to identify the incidence of short-term true outcomes of a syncopal episode, only considering those occurring after a reasonable period of time, with a plausible causal relationship with index syncope as well as syncopal recurrences causing major trauma. METHODS: In this retrospective, observational study, we assessed all patients managed in the emergency department (ED) during a 6-month period, with 30 days of follow-up. RESULTS: The study population consisted of 982 consecutive syncopal patients. We observed short-term serious events, in a broad sense, in 154 patients (15.7%), the most frequent being dysrhythmias (20.8%), cerebrovascular accidents (18.2%), major traumatic injuries (16.2%), death (13%), and myocardial infarction (9.7%). Most of these events (63.6%) could be identified within 72 h, mainly in the ED. Only 19 patients (2.2% of the sample), experienced a true short-term outcome (7 deaths, 1 myocardial infarction, 9 dysrhythmias, 1 major bleeding event, and 1 traumatic syncopal recurrence). CONCLUSIONS: The incidence of short-term true outcomes of syncope is extremely low. Distinguishing true outcomes from other events has a crucial significance for understanding the real prognostic role of syncope and for planning ED management. Once patients with syncope as a direct consequence of an acute disease needing admission by itself are excluded, most patients with unexplained syncope could be safely discharged after primary evaluation and brief ED monitoring

Syncope: current knowledge, uncertainties and strategies for management optimisation in the emergency department

Admission rates and expenditures for syncope remain high. This unsatisfactory management could be due to several factors, including lack of evidence-based strategy, poor accuracy of clinical decision rules, difficulty in disseminating guidelines, as well as uncertainties concerning management of intermediate-risk patients and role of observation protocols and syncope units. To optimise management, it has been proposed to adopt a pragmatic, symptoms-based definition of syncope and a classification related to the underlying mechanism rather than suspected aetiology. It has also been emphasised the importance of identifying patients at intermediate risk as they can be safely discharged after an intensive emergency department evaluation. A further improvement might result from a research implementation to validate the role of observation protocols and to select patients amenable to be sent to outpatient syncope units. Finally, future studies on prognostic significance of syncope should be performed with a more careful selection of outcomes and a greater uniformity

Emergency department management of patients with syncope according to the 2018 ESC guidelines: Main innovations and aspect deserving a further improvement

The approach suggested by the 2018 ESC GL is the main road for achieving the ambitious goal "zero admission for syncope". This document has in fact introduced a clear-cut distinction between syncope associated with a definite diagnosis, which shall be managed according to the underlying condition, and the really undetermined cases, which shall be managed with prognostic stratification. ESC GL also emphasize the pivotal importance of managing patients in facilities such as ED observation syncope units or outpatient syncope clinics, as a safe alternative to admission. Moreover, they provide a table of non-syncopal causes of TLOC to be excluded, indicating the clinical features distinguishing them from syncope, clearly define the indications for additional examinations to be made after the initial evaluation and include a detailed table contains features for stratifying patients as being at high- and low-risk. However, we believe that this approach could be further improved, by especially defining criteria to identify patient neither high nor low risk, to be called at "intermediate-risk", making the prognostic stratification table easier to remember and use, by clarifying the role of laboratory tests to support the clinical judgment and by defining protocol for managing patients ED observation unit

Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis

This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strateg

Emergency diagnostic testing in pregnancy

Emergency diagnostic testing is challenging in pregnancy, whereby some parameters may be modified by the pregnancy and, on the other hand, other laboratory tests are essential for monitoring pregnancy and for diagnosing its potential complications. Owing to a number of physiological adaptations which develop throughout physiological pregnancy, clinically significant changes may develop in the reference ranges of some laboratory tests such blood cell count, urea, creatinine, thyroid hormones, screening hemostasis tests and D-dimer. Reliable evidence is then accumulating that some specific tests may be very useful for diagnosing or ruling out pregnancy-related disorders, especially preeclampsia and even pregnancy-induced hypertension. Therefore, this article aims to provide a concise overview on the significance of emergency diagnostic testing in pregnancy

Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk Syncope) Study

Despite guidelines, admission rates and expenditures for syncope remain high. This may be caused by an imprecise definition of cardiovascular disease considered at risk and an overestimation of the role of comorbidities and advanced age. In a cohort of patients with undetermined syncope, we prospectively compared the short-term prognosis of patients at intermediate risk (i.e., with stable heart diseases or comorbidities, of any age) versus those at high risk for cardiogenic syncope and identified factors associated with serious events. Secondarily, we analyzed the current management of intermediate-risk patients

Emergency physician's perception of cultural and linguistic barriers in immigrant care: results of a multiple-choice questionnaire in a large Italian urban emergency department

A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians (EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department (ED) and their possible associations with demographic data, geographical origin and clinical characteristics