Assessment of a structured management pathway for patients referred to the Emergency Department for syncope: results in a tertiary hospital.

AIMS: High hospitalization rates (39-58% in the literature) of patients admitted to Emergency Department (ED) for transient loss of consciousness (T-LOC) suspected for syncope are still an unresolved issue. The presence of an Observation Unit has reduced hospital admissions and the duration of hospitalization in controlled studies, and a Syncope Unit (SU) in the hospital may reduce hospitalization and increase the number of diagnoses in patients with T-LOC. We assessed the effect of a structured organization on hospitalization rate and outcome. METHODS AND RESULTS: Consecutive patients referred to the ED for a T-LOC of a suspected syncopal nature as the main diagnosis were included. The ED physician was trained to choose between: hospital admission (directly or after short observation); discharge after short (<48-h) observation; discharge on a fast track to the SU; and direct discharge without any further diagnostics. From January to June 2010, 362 patients were evaluated in the ED: 29% were admitted, 20% underwent short observation in the ED, 20% were referred to the SU, and 31% were directly discharged. Follow-up data were available on 295 patients who were discharged alive: of these, 1 (0.3%) previously hospitalized patient died within 30 days and 16 (5.4%) died within 1 year. Death rates were 12.9, 3.3, 0, and 2.5% among admitted, observation, SU, and ED-discharged patients, respectively. No death could be directly attributed to T-LOC. Re-admission within 1 year for any cause occurred in 72 (24%) patients; re-admission rates were 45.9, 19.3, 11.5, and 18.0% among admitted, observation, SU, and ED-discharged patients, respectively. CONCLUSIONS: The availability of short observation and a SU seems to reduce the hospitalization rate compared with previous reported historical reports from our and other centres. Most deaths during follow-up occurred in patients who had been hospitalized. High rates of re-admission to the ED within 1 year are still an issue.

[Evaluation of "complex syncope: what are the indications for second-level investigations?]. / Inquadramento della sincope "difficile": quali sono le indicazioni agli esami di secondo livello?

Syncope is a common symptom accounting for 1.1% of all admissions to the emergency department in Italy. Diagnostic and therapeutic management of patients with syncope may be complex and with a major impact on health expenditure. A standardized approach to syncope may reduce diagnostic tests, hospitalizations and health costs. After the initial "gold standard" evaluation, which includes history, physical examination, orthostatic hypotension test and ECG, several diagnostic pathways can be followed. It has been shown that a correct initial evaluation and a thorough knowledge of syncope can reduce needless testing and increase diagnostic yield, optimizing resource management. In this review we aim to underscore the key points of the management of patients with syncope and the main indications for specific second-level examinations, such as those for neuroautonomic evaluation (tilt table test, carotid sinus massage) and implantable loop recorder. The role of Syncope Units in the management of patients with temporary loss of consciousness is also described.