Evaluating an emergency department observation syncope protocol for older adults

描述(由申请人提供)：本申请涉及广泛的挑战领域(05)：比较有效性研究，以及具体的挑战主题：“05-AG-104.计划拨款和试点研究，用于比较多种共存疾病的老年患者的管理策略。”晕厥，被定义为一过性的意识丧失，每年在美国急诊科就诊超过70万人次，可能预示着老年人(60岁)的生命危险。现有的风险预测工具无法可靠地确定在这些老年患者中，谁可以安全地从急诊科出院。因此，大多数没有明确晕厥原因的老年患者都会住院进行诊断评估。然而，目前的入院做法的特点是诊断率低，没有明显改善结果，每年的医院费用超过24亿美元。大多数住院患者在48小时内出院，大约50%的患者在住院后没有确定的晕厥原因。实施快速和标准化的急诊科观察晕厥方案(EDOSP)可以安全地减少老年晕厥患者的住院率。我们提出了一项试点随机试验，在两个急诊科实施和评估EDOSP。本研究有以下探索性的具体目的：1.比较与标准护理相关的入院率和住院时间。2.比较EDOSP与标准护理的严重结局发生率。3.比较与EDOSP相关的生活质量和标准护理。4.比较EDOSP与标准护理的增量成本和成本-效果。在一年的时间里，120名在两个研究地点出现晕厥的中等风险老年人将被随机分成2组中的1组：1)干预措施：快速和标准化的EDOSP护理；或2.控制臂：由急诊科入院组成的常规护理。如果这项试点试验表明EDOSP可以安全地减少入院人数，那么我们将计划进行一项更大规模的研究，以评估临床、生活质量和经济结果。成功的EDOSP干预将具有重要的临床政策意义，并改善患有晕厥的老年人的急诊科护理。晕厥，也被称为一过性意识丧失，是老年人急诊科就诊的常见原因，可能是严重疾病的先兆。大多数老年人住院接受进一步评估，尽管这种做法的诊断效率很低，而且每年的医院费用为24亿美元。我们将实施和评估一项快速和结构化的急诊科晕厥观察方案，以安全地减少不必要的住院。

DESCRIPTION (provided by applicant): This application addresses the broad Challenge Area (05): Comparative Effectiveness Research, and specific Challenge Topic: "05-AG-104. Planning grants and pilot studies for comparisons of management strategies for older patients with multiple coexisting conditions." Syncope, defined as a transient loss of consciousness, accounts for over 700,000 annual U.S. emergency department visits and may herald a life-threatening condition in older adults (agee60 years). Existing risk prediction instruments cannot reliably identify who among such older patients can safely be discharged home from an emergency department. As a result, the majority of older patients without a clear cause for syncope are hospitalized for diagnostic evaluation. However, current admission practices are characterized by low diagnostic yield, do not clearly improve outcomes, and account for over $2.4 billion in annual hospital costs. Most admitted patients are discharged within 48 hours, and approximately 50% of patients do not have an identified cause of syncope after their hospitalization. The implementation of an expedited and standardized Emergency Department Observation Syncope Protocol (EDOSP) may safely reduce hospitalization of older patients with syncope. We propose a pilot randomized trial to implement and evaluate EDOSP at two emergency departments. This study has the following exploratory Specific Aims: 1. To compare admission rates and length-of-stay associated with EDOSP to standard care. 2. To compare serious outcomes rates associated with EDOSP to standard care. 3. To compare quality-of-life associated with EDOSP to standard care. 4. To compare the incremental costs and cost-effectiveness of EDOSP to standard care. Over a one-year period, 120 intermediate-risk older adults who present with syncope at the two study sites will be randomized to 1 of 2 arms: 1.) intervention arm: expedited and standardized EDOSP care; or 2.) control arm: routine care consisting of admission from the emergency department. If this pilot trial suggests that EDOSP can safely reduce admissions, then we will plan a larger study powered to evaluate clinical, quality-of-life, and economic outcomes. A successful EDOSP intervention would have important clinical policy implications and improve the emergency department care of older adults with syncope. H Syncope, otherwise known as transient loss of consciousness, is a common reason for emergency department visits among older adults and may be a harbinger of a serious medical condition. The majority of older adults are hospitalized for further evaluation, although this practice has low diagnostic yield and is characterized by $2.4 billion in annual hospital costs. We will implement and evaluate an expedited and structured Emergency Department Syncope Observation Protocol to safely reduce unnecessary hospitalizations.