Observation for Fainting Patients is Safe, Less Costly Alternative to Hospitalization

Tuesday, November 09, 2004

ROCHESTER, Minn. Most patients who have fainted do not need to be hospitalized, but can be effectively managed through a short-term observation unit, according to findings of a Mayo Clinic study presented today at the American Heart Association's Scientific Sessions 2004 in New Orleans. The full manuscript from this late-breaking clinical trial also is published today in Circulation: Journal of the American Heart Association.

Syncope, the technical term for fainting, is a common problem responsible for as many as six percent of hospital admissions. The average cost per admission for syncope evaluation is $5,300, and the total annual cost to the U.S. health care system exceeds $1 billion. The Mayo Clinic study, in which a special observation unit reduced admission rates for these patients by more than 50 percent while maintaining long-term survival, could lead to widespread changes that would reduce health care costs without negatively affecting patient outcomes.

"When syncope patients arrive at the emergency department, their symptoms are usually gone, which makes diagnosis difficult," says Win Shen, M.D., the Mayo Clinic cardiologist who led the team. "Sometimes a dangerous heart condition is to blame, but there are many other potential causes of fainting that are bothersome but not worrisome.

Some patients are easily identified as being at high-risk of an adverse event in the short term and therefore should be admitted, while others are clearly at low risk and are discharged quickly. Our study involved those in the middle, who are typically admitted because the emergency department cannot determine the cause of their fainting within the conventional constraints of time and resources or whether they can safely go home."

A team of specialists in cardiology and emergency medicine developed the observation unit with a standard protocol of relatively simple tests for evaluating whether it was safe to send patients home.

The testing included continuous heart-rhythm monitoring, hourly measurements of blood pressure in various body positions, echocardiogram (an ultrasound of the heart), carotid sinus massage with blood pressure and heart rate monitoring, available tilt table testing and electrophysiology consultation.

Only patients considered to be at intermediate risk for an adverse cardiovascular event were enrolled in the three-year study. Participants were randomly assigned to the new observation unit (51 patients), or to receive standard care (52 patients) in the emergency department. During the six hours of observation, the syncope unit confirmed the cause of fainting in two-thirds (34) of the patients, yet only 43 percent (22) required hospital admission. Because so few standard care patients received a definitive diagnosis in the emergency department, 98 percent of them (51) had to be admitted to the hospital for further testing.

Two years after their fainting episodes, 97 percent of the observation unit patients were still alive, as compared with 90 percent of the standard care group. While that difference was not statistically significant, it does indicate that the observation unit was at least as safe as the hospitalization-intense standard care.

The next phase of the analysis, according to Wyatt Decker, M.D., Chair of Emergency Medicine at Mayo Clinic, will be to evaluate which of the tests were most important in identifying fainting causes. "Some of the tests we used do not require special equipment, and could be done in almost any emergency department. Others, such as tilt table testing, are more specialized and are not available everywhere. As we dig deeper into the results from this just-concluded trial, we may find ways to further refine the observation program."

"These results are good news for patients and for the health care system," says emergency medicine specialist Peter Smars, M.D., another study collaborator. "Most patients would like to know they can safely go home instead of having to spend days in the hospital. Depending on their insurance coverage, a hospital admission also may add a significant personal financial burden. Our health care system cannot afford to spend hundreds of millions of dollars hospitalizing people who could be treated just as effectively through short-term observation."

In addition to Drs. Shen, Smars and Decker, other authors of the Circulation paper include Deepi Goyal, M.D., Ann Walker, David Hodge, Jane Trusty, Arshad Jahangir, M.D., Peter Brady, M.D., Thomas Munger, M.D., Bernard Gersh, M.B., Stephen Hammill, M.D. and Robert Frye, M.D. Funding for the study came from Mayo Foundation and Medtronic.
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