Reducing admissions utilizing the Boston Syncope Criteria

Abstract

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.