Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission.

STUDY OBJECTIVE: Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. METHODS: This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. RESULTS: Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. CONCLUSION: An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

Framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department.

BACKGROUND: Wait times and patient satisfaction are important administrative metrics in emergency departments (EDs), as they are critical to return patronage, liability, and remuneration. Although several factors have been shown to impact patient satisfaction, little attention has been paid to understanding the psychology of waiting and patient satisfaction. OBJECTIVE: We utilize concepts that have been applied in other service industries to conceptualize factors that impact patient satisfaction. We focus on wait times, a key factor in patient satisfaction, and describe how these concepts can be applied in research and daily practice. DISCUSSION: Patient satisfaction can be conceptualized as the difference between a patient's perceptions and their expectations. Perception is the psychological process by which an individual understands and interprets sensory information. Changes in the wait experience can decrease the perceived wait times without a change in actual wait times. Other changes such as improved staff interpersonal and communication skills that provide patients with an increased sense of the staff's dedication as well as a greater understanding of their care, can also affect patient perceptions of their care quality. These changes in patient perception can synergize with more expensive investments such as state-of-the-art facilities and increased ED beds to magnify their impact on patient satisfaction. Expectation is the level of service a patient believes they will receive during their ED visit. Patients arrive with expectations around the component of their care such as wait times, needed diagnostic tests, and overall time in the ED. These expectations are affected by individual-specific, pre-encounter, and intra-encounter factors. When these factors are identified and understood, they can be managed during the care process to improve patient satisfaction. CONCLUSION: Interventions to decrease perception of wait times and increase the perception of service being provided, when combined with management of patient expectations, can improve patient satisfaction.