Optimizing risk stratification, orthostatic vital signs and carotid doppler use in patients admitted with syncope in a community hospital in south Texas

From the 2023 HVPA National Conference

Oscar Zamudio MD (University of Texas Rio Grande Valley), Remus Popa MD (University of California Riverside School of Medicine), Fatimah Bello MD

Background:
Syncope is a common condition defined as loss of consciousness due to transient global cerebral hypoperfusion with spontaneous complete recovery. Syncope etiology is broad and initial evaluation complex. Hence a systematic approach is important for an accurate diagnosis and risk stratification. In-patient management of syncope represents a large economic burden for health care, with raising costs in the past decade. Overuse of auxiliary tests, laboratory analysis and imaging continue to be a problem. Guideline directed recommendations have been published. However, its application is deficient, leading to poor resource utilization.

Objective:
Improve measurement of orthostatic vital signs and reduce the use of carotid doppler in patients admitted with syncope.

Methods:
This was a 13-month, retrospective pre and post intervention study that examined the rates of orthostatic vital signs (OVS), carotid doppler ultrasound (CD) and risk stratification in patients admitted with diagnosis of syncope in a single center. The rates calculated were interpreted as a marker of adherence to current guidelines.

Baseline rates were obtained after retrospective evaluation of medical records (June 2020 to July 2021), a total of 166 cases were identified and 99 met selection criteria. In the post intervention period, a total of 48 cases were included in the study. A series of PDSA cycles were implemented in month 1, 5 and 9. Interventions included education to physicians, followed by education to other key stakeholders (physician and nursing staff), using visual aids as a reminder of guideline recommendations. Lastly the implementation of a syncope EMR template that included clinical variables, a risk stratification tool (Canadian syncope risk score), and an order set.

Results:
Preintervention group included a total of 99 patients, baseline rates included orthostatic vital signs (12.12%), carotid doppler (13.9%), and risk stratification assessment (0%) (Figure.1). Compared to baseline characteristics, higher rates of OVS and lower rates of CD were achieved after month 1 and month 7 respectively. Our first intervention led to an increase in rates of OVS peaking at 80% with a subsequent decrease to 28.57% by month 5. The second intervention showed a similar trend, peaking at 67% and declining to 33.3% by month nine. Our third intervention led to an increased rate of orthostatic vital signs, with 3 measurements above the median (Figure 1). After the first PDSA cycle, carotid doppler ordering rates remained elevated compared to baseline for 6 months (14%-33%). The second and third intervention lowered the ordering rate of CD ultrasound. These last interventions were effective and sustained for more than 5 months, with more than 6 measurements below the median (Figure.2). Risk stratification and EMR template use increased in the last 4 months of the study.

Conclusion: 
Education alone increased the rate of orthostatic vital signs but was not sufficient to achieve a significant impact on improvement. Its effect decreased overtime. Education along with an EMR template with a risk stratification tool, and clinical variables showed improvement in limiting unnecessary testing, particularly carotid doppler in patients admitted with syncope. Our last intervention could potentially reduce costs in syncope admissions. Larger studies may further elucidate this question.

Clinical Implications:
Locally we were able to improve adherence to guidelines and better use of resources, particularly carotid doppler. Our findings led to higher rates of risk stratification and orthostatic vital signs examination as part of the initial syncope examination.

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