Emergency department management of syncope: need for standardization and improved risk stratification.

Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

Outcomes in presyncope patients: a prospective cohort study.

STUDY OBJECTIVE: Presyncope is the sudden onset of a sense of impending loss of consciousness without losing consciousness (which differentiates it from syncope). Our goals are to determine the frequency of emergency department (ED) presyncope visits, management, 30-day outcomes, and emergency physicians' outcome prediction. METHODS: Our prospective study at 2 academic EDs included adults with presyncope and excluded patients with syncope, mental status changes, seizure, and significant trauma. We collected patient characteristics, ED management, cause (vasovagal, orthostatic, cardiac, or unknown) at the end of the ED visit, and 30-day outcomes. Serious outcomes included death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage. We also collected physicians' confidence in assigning the cause and their prediction probability for 30-day serious outcomes. RESULTS: Presyncope constituted 0.5% of ED visits. We enrolled 881 patients: mean age 55.5 years, 55.9% women, and 4.7% hospitalized. Among 780 patients with 30-day follow-up, 40 (5.1%) experienced serious outcomes: death 0.3%, cardiovascular 3.1%, and noncardiac 1.8%. Of the 840 patients discharged home, 740 had follow-up data and 14 patients (1.9%) experienced serious outcomes after ED disposition. The area under the receiver operating characteristic curve for physician prediction probability was 0.58 (95% confidence interval 0.38 to 0.78). The incidence of serious outcomes was similar, whereas physician diagnostic confidence and prediction probability varied among the 4 causal groups. CONCLUSION: Presyncope can be caused by serious underlying conditions. Emergency physicians had difficulty predicting patients at risk for serious outcomes after ED discharge. Future studies are needed to identify risk factors for serious outcomes after ED disposition.

Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients.

BACKGROUND: Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death. OBJECTIVE: The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients. METHODS: We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning. RESULTS: There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2-58.5), decreased sensation on physical examination (OR 6.9; CI 2.2-21.2), pain that is worse at night (OR 4.3; CI 0.9-20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8-5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70-98%) and 55% specificity (95% CI 54-56%). CONCLUSION: We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.