Implementing a Guideline to Improve Management of Syncope in the Emergency Department

Study Design, Setting, and Population

Using a quasi-experimental study design, we reviewed clinical data from patients who presented from July 1, 2010, through October 31, 2012, during which time we implemented a quality improvement intervention for pediatric syncope.

We included children 8 to 22 years old presenting with syncope or presyncope to the ED of a large urban tertiary care children’s hospital, with an annual volume of 59 000 visits per year. This ED is staffed by 48 board-certified pediatric emergency medicine specialists, 26 board-certified general pediatricians, 18 pediatric emergency medicine fellows, more than 200 rotating pediatric and emergency medicine residents from 4 residency programs, rotating third- and fourth-year medical students, and 100 nurses.

We defined syncope as a transient brief loss of consciousness associated with loss of postural tone with spontaneous recovery, and presyncope as a near-fainting episode, which may include lightheadedness, dizziness, severe weakness, and blurry vision without loss of consciousness.^1,17–19 We included syncope and presyncope in the study because of the real-time difficulty in ascertaining brief loss of consciousness among these patients, many of whom experience these events unwitnessed. This is the primary characteristic used to distinguish presyncope from syncope. Patients with complaints of syncope and presyncope overlap significantly, with most sharing the basic physiology of neurally mediated syncope and the concomitant low frequency of serious disease. At their extremes, the distinction between syncope and presyncope is clear (the abrupt convulsive event or the mildly lightheaded patient who is not having to catch himself or herself). In practice, the clarity of whether a child actually lost consciousness or not is often not entirely clear at the time of the ED evaluation. We excluded patients who were ill-appearing as determined by the treating attending physician; had a history of active cardiac or neurologic disease; had significant comorbidity, such as diabetes; had a known toxic ingestion; or had any major trauma preceding the syncopal episode. In addition, we excluded patients who were transferred from another hospital and had any diagnostic testing performed at the transferring institution. Our study criteria were the same as the inclusion and exclusion criteria referenced on the clinical guideline (Supplemental Information).

Patient Identification/Enrollment

Patients were screened through the use of chief complaint codes, which the triage nurse selects from a prepopulated list to categorize a patient’s reason for visit. To improve capture of patients with possible syncope, research coordinators identified potentially eligible patients by real-time monitoring of an electronic tracking system for chief complaints of either “syncope” or “dizziness.” The physician caring for the child confirmed eligibility for the study based on the stated inclusion and exclusion criteria.

Physicians caring for study subjects were asked to complete a tablet-based electronic survey after their evaluation of the patient. The research coordinator approached the patient and parent and obtained written informed consent (or assent) for study participation. Subjects consenting/assenting to participation agreed to be contacted via phone or E-mail 2 months after the initial ED visit, to quantify subsequent episodes of syncope, additional follow-up visits, or diagnostic testing performed outside the study hospital. Two months was chosen as the follow-up interval to permit enough time for patients or their parents to schedule or attend specialty appointments. An automated E-mail was sent to study investigators on a daily basis containing a list of all patients with chief complaints of dizziness or syncope from the previous day. Patients who were eligible but not enrolled during the ED visit were screened for inclusion by study investigators (SG, AF). The physician survey was generally completed at the time of the patient encounter; however, in an effort to maximize enrollment, we notified clinicians of the missed eligible patients with syncope the following day, and allowed then to complete the survey at that time. This information was collected as soon as possible after the ED visit. We attempted to contact the patient/parent to collect follow-up information 2 months after their visit. For these families, an informational packet was mailed with an opportunity to opt-out of the study before any phone contact. If the family did not opt out, attempts were made by the research coordinators to contact the family and obtain consent for follow-up.

Intervention

Data Collection

We reviewed the complete medical records via direct chart review of all study patients and abstracted demographic data, historical data, physical examination findings, ancillary test results (laboratory data, ECG, and imaging findings), administration of medications and/or intravenous fluids, consultations obtained, patient disposition, and outcomes.

In an effort to standardize ECG interpretation, we included in the algorithm a standardized checklist to assist clinicians in classifying a patient’s ECG as normal, borderline, or abnormal. This checklist includes moderately stringent criteria for abnormal values to ensure appropriate cardiology consultation at the time of the visit or outpatient follow-up in the cardiology clinic (Supplemental Information). In our ED, the standard practice is for all ECGs to be interpreted by an emergency medicine attending physician. A pediatric cardiology attending physician also reviews every ECG; 85% are reviewed within 24 hours, and 95% within 72 hours of the ED encounter. If an abnormality is identified by the cardiologist that was not identified by the ED physician, the pediatric cardiologist notifies the on-call ED attending to coordinate appropriate patient follow-up.

The questionnaire for the ED physicians aimed to capture information not consistently documented in the medical record. For example, the survey asked the clinicians if anemia was on their differential diagnosis, enabling investigators to speculate if a CBC were obtained for a specific concern of anemia, rather than simply a reflexive screen for syncope.

Patient follow-up via phone or E-mail occurred approximately two months from the index visit (for patients enrolled in the prospective arm of the study) to identify subsequent episodes of syncope, additional follow-up visits, or diagnostic testing performed outside the study hospital. In addition, we inquired about patient and family satisfaction with the initial ED visit. For patients who we were unable to contact, the electronic medical record was queried for 3 months after the ED visit to identify follow-up visits at the study hospital (ED, hospital-affiliated primary care, and subspecialty), additional diagnostic evaluation, and additional diagnoses.

Two chart abstractors (SG, MO) independently reviewed 10% of randomly selected charts to assess interrater reliability of whether specific diagnostic testing was obtained, using the κ statistic. We observed perfect agreement (κ = 1.0) for the rates of performance of urine pregnancy testing, CBC, and electrolytes.

Study data were collected and managed using the Research Electronic Data Capture, a secure Web-based application designed to support data capture for research studies.

Statistical Analysis

We used χ² tests to compare the proportion of children undergoing diagnostic testing as a summary outcome before and after guideline implementation; α was set at 0.05 and all tests were 2-tailed. Statistical analyses were conducted by using JMP Pro 10 (JMP Statistical Software; SAS Institute, Inc, Cary, NC). Statistical run charts were constructed to monitor improvement over time. For each outcome, the percent of patients undergoing a specific test was calculated.