急诊室晕厥观察方案安全且省钱

丹佛——俄勒冈健康与科学大学的Benjamin Sun博士在美国急诊医师协会(ACEP)年会上报告称，一种针对不明原因晕厥患者的急诊室观察方案，可有效减少医务人员工作量和费用，而且没有证据表明该方案可导致伤害。


Benjamin Sun博士

这项多中心随机试验在5家医院开展，结果显示这种晕厥观察方案适用于急诊室，不论其属于大学附属医学中心、小型社区医院还是大型公立医院。

这种观察方案是针对年龄超过50岁、严重事件(如卒中、心肌梗死或危及生命的心律不齐)风险为中度的急诊晕厥患者设计的。对于明显高危的晕厥患者，例如合并危险心律失常或心肌梗死者，应常规直接收住院治疗。对于低危的晕厥患者——可能因某种良性原因(例如血管迷走神经性或直立性)导致的晕厥，可很快让其出院。

这种观察方案的核心元素包括连续肌钙蛋白检测、12~24 h心电图监测，以及选择性使用超声心动图检查。是否实施头部CT和其他辅助检查由医生自行判断，参加该研究的各个中心的做法差异较大。

本项研究共招募了124例中危急诊患者，随机分组采取急诊室观察方案或常规住院患者非结构化处理。

结果显示，急诊室观察方案产生了惊人的费用节省效果：仅有11%的患者最终被收住院，其中约80%是由于在急诊室观察期间发现心律失常，其余20%是由于肌钙蛋白漏。接受急诊室观察的晕厥患者的平均留院时间为29 h，而对照患者长达46 h。两组患者的30天医院费用分别平均为2,100美元和3,500美元。

两组的出院后30天和6个月卒中、心肌梗死或肺栓塞等严重不良事件的发生率均较低，无明显差异。两组的生活质量评分也相似，提示急诊室观察方案在节省费用的同时并不会带来危害。

美国每年有超过700,000万例晕厥患者被送至急诊室，这些患者常常会被收住院，即使其风险并不高。因晕厥而住院每年会产生超过240亿美元的医疗费用，而所带来的获益却并不明确。

Sun博士无相关利益冲突披露。

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By: BRUCE JANCIN, Cardiology News Digital Network

DENVER – An emergency department protocol for observing patients who present with unexplained syncope substantially reduced health care services and costs with no evidence of harm, compared with routine hospital admission for observation.

The findings were seen in a multicenter randomized trial conducted in five diverse hospital settings, indicating the syncope observation protocol is applicable in EDs regardless of whether they’re located in academic medical centers, small community hospitals, or big county public hospitals, Dr. Benjamin Sun noted at the annual meeting of the American College of Emergency Physicians.

The observation protocol is designed for syncope patients over age 50 identified in the ED as being at intermediate risk for subsequent serious events such as stroke, MI, or life-threatening arrhythmia.

Patients clearly at high risk, such as those who presented with syncope related to a dangerous arrhythmia or an MI, were routinely admitted straightaway for inpatient care. Those whose syncope was identified in the ED as low-risk – that is, likely due to a benign cause such as vasovagal or orthostatic syncope – were quickly discharged, explained Dr. Sun of Oregon Health and Sciences University, Portland.

The core elements of the observation protocol consisted of serial troponin testing, 12-24 hours of ECG monitoring, and selective use of echocardiography. Head CT and other ancillary testing was done at physician’s discretion and varied widely among the study sites according to local practice. The ED syncope observation units were run by emergency physicians and staffed by mid-level providers.

Dr. Sun reported on 124 intermediate-risk patients at five participating EDs who were randomized to the ED observation protocol or to routine inpatient unstructured care, which is how such patients are typically managed in the United States.

The ED-run protocol resulted in dramatic savings: Only 11% of patients assigned to that strategy were ultimately admitted to the hospital. Roughly 80% of those admissions occurred because an arrhythmia was identified during ED observation, while the other 20% were due to troponin leaks. The mean length of stay for syncope patients assigned to ED observation was 29 hours, compared with 46 hours for controls. Thirty-day hospital costs averaged $2,100 in the ED observation group compared with $3,500 for controls.

Rates of serious adverse events such as stroke, MI, or pulmonary embolism within 30 days and 6 months post discharge were in similarly low single figures in both study arms. Quality of life scores in the two groups were also similar, bolstering the conclusion that the ED syncope observation protocol saved money without causing harm, Dr. Sun continued.

The ED protocol was developed in an effort to come up with a better way to manage the more than 700,000 patients per year who present with syncope to EDs. Such patients are frequently hospitalized, even if they’re at low or intermediate risk. Hospitalizations for syncope account for more than $2.4 billion annually in health care costs with little evidence of benefit. Medicare has identified this line item as a high-priority target for cost reduction, he noted.

Dr. Sun reported having no financial conflicts.