Do outcomes of near syncope parallel syncope?

Background

Limited information on the evaluation of emergency department (ED) patients complaining of “near syncope” exists. Multiple studies of syncope exclude near syncope claiming near syncope is poorly defined and its definition is nonuniform.

Objective

The aim of this study was to determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope.

Methods

Prospective, observational study enrolling (August 2007-October 2008) consecutive ED patients (age, ≥18 years) presenting with near syncope was conducted. Near syncope was defined as an episode in which the patient felt they might lose consciousness but did not. Critical intervention/adverse outcome was defined as hemorrhage, cardiac ischemia/intervention, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, dysrhythmia, sepsis, pulmonary embolus, or carotid stenosis. Primary outcome was an adverse outcome or critical intervention in hospital or less than 30 days. Near syncope and syncope outcomes and admission rates were compared using the χ² test.

Results

After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001).

Conclusion

Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted. Given similar risk of adverse outcomes for near syncope and syncope, future studies are warranted to improve the treatment of ED patients with near syncope.     

Can Benign Etiologies Predict Benign Outcomes in High-Risk Syncope Patients?

Background: We previously studied and validated risk factors for adverse outcomes or need for critical intervention in syncope. Objective: To determine whether high-risk patients, diagnosed with benign etiologies of syncope after a normal emergency department (ED) work-up, sustain favorable outcomes. Methods: Prospective, observational cohort of consecutive ED patients aged ≥ 18 years with syncope. Benign etiology was defined as vasovagal syncope or dehydration. Patients were followed up to 30 days to identify adverse outcomes including death, myocardial infarction, dysrhythmia, alterations in antidysrhythmics, percutaneous intervention, pulmonary embolus, stroke, metabolic catastrophe, or significant hemorrhage. Results: Patients presented with benign etiologies in 164/293, 56% (95% confidence interval [CI] 50–62%) of cases. Of these, pathologic conditions were identified during ED evaluation in 11/164, 7% (95% CI 3–11%) of cases. This includes ED findings/treatments of blood transfusion, severe electrolyte disturbance, incarcerated hernia, rhabdomyolysis, subarachnoid hemorrhage, bowel obstruction, dysrhythmia, and transient ischemic attack. The remaining 153 with benign presentations had no adverse outcomes at 30 days, while 57/129 (44%) patients with non-benign etiologies had adverse outcomes in the hospital or within 30 days. Previously, we demonstrated a 48% reduction in admission rate if only patients with risk factors for adverse outcome were admitted. If patients with both benign etiologies and a negative ED work-up were sent home, even if they had risk factors for an adverse outcome, an additional 19% (95% CI 14–25%) reduction in hospital admissions would have occurred. Conclusions: In patients with presentations consistent with a benign etiology of syncope (vasovagal or dehydration) where the ED work-up was normal, we found no patients who would benefit from hospitalization based on risk factors alone.     

Applying the Boston Syncope Criteria to Near Syncope

Background

We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well.

Objective

To determine if BSC accurately predict which near-syncope patients require hospitalization.

Methods

A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls.

Results

Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up.

Conclusion

Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.     

Reducing admissions utilizing the Boston Syncope Criteria

Background

We previously developed criteria to identify patients with syncope at risk for adverse events. Although we proposed a theoretical substantial reduction in admission, these criteria were untested in actual practice.

Objective

To perform a prospective effectiveness study testing the hypothesis that using the Boston Syncope Criteria as a clinical guideline will safely reduce the proportion of patients admitted with syncope.

Methods

A prospective, before-and-after cohort study of consecutive Emergency Department (ED) patients presenting with syncope. After in-service training, the Boston Syncope Criteria were implemented as a clinical guideline for emergency physicians who were encouraged to make admission decisions based on the criteria adverse outcomes at 30-day follow-up, including death, myocardial infarction/intervention, dysrhythmia or alterations in dysrhythmics, pulmonary embolus, stroke, or hemorrhage. Operating characteristics of the rule and 95% confidence intervals (CI) were calculated.

Results

In the “before” phase, 201/293 (69%; 95% CI 63–74%) patients with syncope were admitted, compared to 160/277 (58%; 95% CI 52–64%) after the criteria were introduced; an 11% reduction in admission. Among the 160 patients admitted after the intervention, 64 (40%) had adverse events during hospitalization, compared to none in the discharged group. At 30-day follow-up, 6 additional patients (4%) had adverse outcomes; all were admitted initially. Real-time application of the criteria had a sensitivity of 100% (95% CI 94–100%), a specificity of 57% (95% CI 50–63%), and a negative predictive value of 100%.

Conclusion

In our ED, implementing the Boston Syncope Criteria safely reduced admissions to the hospital. Future studies are needed to test external validity and generalizability.     

A Prediction Rule to Identify Low-risk Patients with Heart Failure

Objectives: To derive a prediction rule using data available in the emergency department (ED) to identify a group of patients hospitalized for the treatment of heart failure who are at low risk of death and serious complications. Methods: The authors analyzed data for all 33,533 patients with a primary hospital discharge diagnosis of heart failure in 1999 who were admitted from EDs in Pennsylvania. Candidate predictors were demographic and medical history variables and the most abnormal examination or diagnostic test values measured in the ED (vital signs only) or on the first day of hospitalization. The authors constructed classification trees to identify a subgroup of patients with an observed rate of death or serious medical complications before discharge < 2%; the tree that identified the subgroup with the lowest rate of this outcome and an inpatient mortality rate < 1% was chosen. Results: Within the entire cohort, 4.5% of patients died and 6.8% survived to hospital discharge after experiencing a serious medical complication. The prediction rule used 21 prognostic factors to classify 17.2% of patients as low risk; 19 (0.3%) died and 59 (1.0%) survived to hospital discharge after experiencing a serious medical complication. Conclusions: This clinical prediction rule identified a group of patients hospitalized from the ED for the treatment of heart failure who were at low risk of adverse inpatient outcomes. Model performance needs to be examined in a cohort of patients with an ED diagnosis of heart failure and treated as outpatients or hospitalized.     

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

Objective: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. Methods: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18–65 years with a serious head injury (AIS ⩾3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. Results: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. Conclusions: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.     

Application of San Francisco Syncope Rule in elderly ED patients

Objectives

The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope.

Methods

A retrospective review of ED patients aged 65 years and older with syncope or near-syncope between January 2000 and August 2001 was performed. Charts were reviewed for evidence of SFSR risks for the ED visit and serious outcomes within 7 days of the ED visit.

Results

Of 773 subjects identified as having syncope or near-syncope, 517 subjects were included. There were 98 patients with serious outcomes. Twenty-three patients who were negative on SFSR had serious outcomes. The sensitivity and specificity of the SFSR were 76.5% (95% confidence interval [CI], 66.7%-84.3%) and 36.8% (95% CI, 32.2%-41.6%), respectively. The negative and positive predictive values were 87.0% (95% CI, 80.9%-91.4%) and 22.1% (95% CI, 17.8%-26.9%), respectively.

Conclusions

In our cohort of elderly ED patients, the SFSR had a lower sensitivity and specificity. The SFSR may not be applicable to the elderly ED population. Future prospective validation is necessary before application to the ED elderly population.     

Do patients with a negative Emergency Department evaluation for syncope require hospital admission?

Is hospitalization needed for patients in whom an underlying cause of syncope is not detected in the Emergency Department (ED)? To answer this question, we conducted a prospective, short-term outcomes study of consecutive patients > or = 50 years old presenting to our ED after a syncopal episode. All subjects received a structured ED evaluation. Forty-five patients met inclusion criteria, 67% were hospitalized. None of the patients experienced a life-threatening event or required significant therapeutic interventions during the hospitalization. No patient had a new diagnosis relevant to syncope. Follow-up interviews 1 month later revealed no repeat ED visits, hospitalizations, or deaths (95% upper CI, 6.5%). One patient reported a recurrent syncope (recurrence 2.2% [95% upper CI, 10%]). This pilot study suggests that a negative structured ED evaluation may identify patients > or = 50 years of age who may be safely discharged from the ED. Further validation is required before this observation is applied to clinical practice.     

Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation

Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.     

Relative utility of serum troponin and the OESIL score in syncope

Objective: To investigate the utility of both a random troponin T level taken greater than 4 h after a syncopal event and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score in predicting outcome post syncope. Methods: We prospectively enrolled 113 adult patients who presented to our ED after a syncopal event. Each patient had a troponin T level taken at least 4 h after the event. The relevant history of the syncope, background medical history and ECG were collected at presentation. Patients were followed up via telephone after 3–6 months and medical records were also examined. The OESIL risk score was calculated for each patient and the predictive value of both the troponin T and OESIL score were analysed for their utility post syncope. Results: Data were analysed for 100 patients. Twenty percent were believed to have a cardiac cause for their syncope. An elevated troponin T level was found to be highly specific (0.99, 95% confidence interval [CI] 0.96–1.0) for adverse cardiac outcome, but with a very low sensitivity (0.13, 95% CI 0–0.3). The OESIL risk score was found to be predictive of an adverse cardiac outcome (receiver–operating characteristic [ROC] 0.73, 95% CI 0.63–0.84) and return to normal function (ROC 0.74, 95% CI 0.63–0.86). Conclusions: A normal serum troponin T has a poor negative predictive value for adverse cardiac outcomes following syncope. A simple risk stratification system, such as the OESIL score, can predict those patients most at risk after a syncopal episode.     

Derivation of a clinical prediction rule for evaluating patients with abdominal pain and diarrhea

Objective

The objective of the study was to develop a simple prediction rule to reliably identify abdominal pain patients with diarrhea who may require surgical intervention.

Methods

We performed a secondary analysis of a prospective cohort study of adults with acute nontraumatic abdominal pain and diarrhea in an urban emergency department (ED). Structured data collection included 109 historical and 28 physical examination items, laboratory and radiographic results, and final diagnosis. The main outcome was operative intervention.

Results

One thousand patients were enrolled; 174 patients with diarrhea were included in this analysis. Patients had a mean age of 39 ± 16 years and were likely to be female (64%) and black (60%). Fifteen (9%) patients received a surgical intervention from the ED. Clinical variables associated with the need for surgical intervention using univariate analysis were age older than 40 years, constant pain, and peritonitis on examination. Using recursive partitioning multivariate analysis, the derived prediction rule included 2 variables: age older than 40 years and constant pain. This rule had a sensitivity of 1.0 (95% confidence interval, 0.78-1.0) and specificity of 0.23 (95% confidence interval, 0.16-0.30).

Conclusion

Patients older than 40 years with constant abdominal pain and diarrhea are likely to have a surgical cause of their symptoms.     

Use of age shock index in determining severity of illness in patients presenting to the emergency department with gastrointestinal bleeding

ObjectivesThis study aimed to make a comparison between classical shock index (SI), modified shock index (MSI), and age shock index (age SI) for predicting critical patients presenting to the emergency department (ED) with gastrointestinal bleeding (GIS).MethodsThe study, which was planned retrospectively, consisted of patients diagnosed with GIS bleeding at the ED admission. Triage time vital signs were used to calculate SI, MSI, and age SI. These results were compared with intensive care admission, endoscopic/colonoscopic (E/C) intervention, blood transfusion, and mortality criteria, which we define as adverse outcomes.ResultsThe study included 151 patients. Seventy-nine (52.32%) of the patients had at least one adverse outcome. Of the 151 patients, 19 (12.58%) had ICU admission, 27 (17.88%) underwent endoscopic/colonoscopic (E/C) intervention, 68 (45.03%) received a blood transfusion, and 6 (3.97%) died. There was a significant difference between patients who had no adverse outcome and those who had at least one adverse outcome in terms of SI, age SI, and MSI. We performed ROC curve analyses to evaluate the diagnostic performances of all indices for predicting adverse outcomes. AUC (area under the curve) values for age SI was the highest (age SI AUC = 0.711, p < 0.001; SI AUC = 0.616; MSI AUC = 0.617). The performance of the age SI was significantly higher than the SI (p = 0.013) and the MSI (p = 0.024) for predicting adverse outcomes. The cut-off value for the age shock index was 45.12.ConclusionsIn patients with GIS bleeding, age SI, which can be easily calculated in triage, is more significant than SI and MSI for predicting the critical patient.     

Soft Tissue Infections and Emergency Department Disposition: Predicting the Need for Inpatient Admission

Objectives: Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study’s objective was to generate a clinical decision rule to predict the need for greater than 24‐hour hospital admission for patients presenting to the ED with soft tissue infection. Methods: This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24‐hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression. Results: A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24‐hour admission. Using CART, the strongest predictors of >24‐hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37°C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients. Conclusions: Although we were unable to generate a high‐sensitivity decision rule to identify ED patients with soft tissue infection requiring >24‐hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24‐hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.     

Outcomes in Canadian Emergency Department Syncope Patients – Are We Doing a Good Job?

Background

Little is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs).

Objectives

We sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital.

Methods

We conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED.

Results

Of the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up.

Conclusion

Although syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes.     

ED management of pediatric syncope: searching for a rationale

Objective

The aim of this study was to evaluate emergency department (ED) management of childhood syncope, focusing on diagnostic tests ordered, whether a reason for specific testing was recorded, and hospital admission rates.

Methods

We reviewed ED records of patients aged 5 to 20 years who presented to a community hospital ED with syncope or near-syncope over a 1-year period (April 1, 2004, to March 31, 2005). Patient charts were nonelectronic (paper). We reviewed the elements of the recorded history and physical examination for each patient. The specific tests ordered in the ED were classified into 3 general testing categories for each patient as follows: (1) simple testing, with a hospital charge of $100 or less per test; (2) expanded testing, more than $100 per test, with a recorded explanation; and (3) expanded testing without a recorded explanation.

Results

The charts of 140 patients were reviewed. Of these, we excluded 27 based on exclusion criteria, including history of neurologic disorders. The mean age of the remaining 113 patients was 14.8 ± 3.3 years. Most (80%) presented with syncope; 20% had near-syncope. Ten percent were admitted to the hospital, over half for an electrocardiogram (ECG) interpreted as abnormal by an ECG machine and/or the ED staff. Overall, 17.5% of patients had simple testing, 32.5% had expanded testing with explanation, and 50% had expanded testing without explanation. Patients with syncope were more likely than patients with near-syncope to be in the expanded testing category (P < .008). The most commonly ordered tests in the ED in order of decreasing frequency were electrolytes (90%), ECG (85%), complete blood count (80%), urinalysis, urinary drug screen, or urinary human chorionic gonadotropin (76%), head computed tomography (CT, 58%), and chest x-ray (37%). The most expensive of these tests was the head CT; all head CT results were negative.

Conclusions

A relatively high number of our subjects were admitted (10%), most often because of questions raised by the ECG. Although an ECG is widely recommended for pediatric syncope presenting to the ED, this suggests that ECG interpretation by a pediatric cardiologist would be helpful before the decision to admit is made. In addition, 58% of our subjects had a head CT in the ED; all CT results were negative. This high percentage of head CTs for pediatric syncope has not been previously reported.     

Preliminary development of a clinical decision rule for acute aortic syndromes

ObjectivePatients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule.MethodsWe retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm.ResultsOf the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84).ConclusionsOur results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.     

Multicenter Validation of the Philadelphia EMS Admission Rule (PEAR) to Predict Hospital Admission in Adult Patients Using Out-of-hospital Data

Objectives:  The objective was to validate a previously derived prediction rule for hospital admission using routinely collected out-of-hospital information.
Methods:  The authors performed a multicenter retrospective cohort study of 1,500 randomly selected, adult patients transported to six separate emergency departments (EDs; three community and three academic hospitals in three separate health systems) by a city-run emergency medical services (EMS) system over a 1-year period. Patients younger than 18 years or who bypassed the ED to be evaluated by trauma, obstetric, or psychiatric teams were excluded. The score consisted of six weighted elements that generated a total score (0–14): age ≥ 60 years (3 points); chest pain (3); shortness of breath (3); dizzy, weakness, or syncope (2); history of cancer (2); and history of diabetes (1). Receiver operator characteristic (ROC) curves for the decision rule and admission rates were calculated among individual hospitals and for the entire cohort.
Results:  A total of 1,102 patients met inclusion criteria. The admission rate for the entire cohort was 40%, and individual hospital admission rates ranged from 28% to 57%. Overall, 34% had a score of ≥4, and 29% had a score of ≥5. Area under the ROC curve (AUC) for the combined cohort was 0.83 for all admissions and 0.72 for intensive care unit (ICU) admissions; AUCs at individual hospitals ranged from 0.72 to 0.85. The admission rate for a score of ≥4 was 77%; for a score of ≥5 the admission rate was 80%.
Conclusions:  The ability of this EMS rule to predict the likelihood of hospital admission appears valid in this multicenter cohort. Further studies are needed to measure the impact and feasibility of using this rule to guide decision-making.     

Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode.

A Method for Improving Arrival-to-electrocardiogram Time in Emergency Department Chest Pain Patients and the Effect on Door-to-balloon Time for ST-segment Elevation Myocardial Infarction

Objectives: The objectives were to determine if an emergency department (ED) could improve the adherence to a door‐to‐electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door‐to‐balloon (DTB) time for ST‐segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. Methods: This was a planned 1‐month before‐and‐after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. Results: A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty‐nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions: The overall percentage of patients with a door‐to‐ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.