Background: Evidence-based medicine is inconsistently used in the evaluation of syncope, leading to misutilization of resources. We studied the effect of a multifaceted intervention on the adherence to evidence based recommendations.
Methods: A multidisciplinary group developed an evidence based syncope algorithm that included a risk stratification tool. Educational (ED nursing education on orthostatic vital signs OVS, physician education on syncope guidelines) and electronic medical record (EMR) interventions were implemented (preselected ECG and OVS orders, note template to prompt collection of pertinent history, link to syncope algorithm on intranet).Emergency and Internal Medicine physicians independently reviewed charts of syncope patients seen in the ED April – June 2011 (Pre) and 2013 (Post). Clinical data and tests performed/recommended were analyzed for their appropriateness per protocol. Adverse outcomes (ICU admission, blood transfusions, cardiac catheterization, pacemaker/AICD placement, ED readmission or death within 30 days) were tracked. Fisher exact test using STATA was used to determine statistical significance.
Results: There were 138 cases in the Pre and 175 in the Post intervention group. In the Pre group 77 patients were assessed as low risk (LR) and 61 as high risk (HR) compared to 112 LR and 63 HR in the Post group. There was a significant improvement in obtaining OVS (p<0.001) and documentation of history pertinent to risk stratification (p<0.05) for all patients, as well as overall reduction in excessive testing. In the HR group, a significant reduction in unnecessary testing (Troponin, Telemetry, Echocardiogram, head CT) post intervention was observed. In the LR group, the only significant reduction post intervention was in telemetry utilization.
Conclusions: The interventions were successful in reducing excessive testing in all patients. Significant gains were noted for interventions hardwired in the EMR. In contrast, testing left to the physicians’ discretion, with guidance only, led to variation of utilization by risk class. In the LR group, cardiac testing and head CT were the most excessive and our interventions had no impact. Conversely, significant decrease in ordering the same tests in the HR group was noted. We suggest that an evidence based practice guideline embedded in the EMR workflow could lead to a decrease in resource overutilization in syncope patients. Differences in resource utilization patterns and response to interventions between HR and LR patients should be considered when designing future interventions.
To cite this abstract:Patrawala, S; Farkhondehpour, M; Oyama, L; Popa, R . STRATEGIES FOR GUIDELINE ADHERENCE IN SYNCOPE DIAGNOSIS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 205. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/strategies-for-guideline-adherence-in-syncope-diagnosis/. Accessed September 22, 2019.