Aims: To establish the current practice of emergency department (ED) management of syncope in the UK and Republic of Ireland.
Methods: A survey of “major” or “intermediate” size ED in the UK and Republic of Ireland conducted by postal and telephone questionnaire.
Results: 177 (70%) ED responded. 32 (18%) ED have syncope guidelines, which are based on a range of existing guidelines. 97 ED (55%) have an observation ward or clinical decision unit and 48 (49%) of these admit syncope patients to these units. 32 ED (18%) have access to a specialist syncope outpatient clinic. This is most likely to be run by general practitioner specialists (43%) or general physicians (24%). 81% of ED felt that improved research-based guidelines would be useful when managing syncope patients.
Conclusion: The ED management of syncope patients in the UK and Republic of Ireland is varied. Only 18% of ED have specific guidelines for managing this difficult condition and only 18% have access to a specialist syncope clinic. A robust consensus UK syncope guideline is clearly required.
Statistics from Altmetric.com
Syncope is a sudden but brief loss of consciousness with an inability to maintain postural tone followed by a spontaneous recovery. It is a common presentation to the emergency department (ED), accounting for between 1% and 2% of all visits each year.1 As the causes of syncope range from the benign to the life threatening, it is important to establish the risk to the patient as effectively as possible. Several guidelines and risk stratification tools exist aiming to identify high-risk patients requiring further investigation accurately and low-risk patients who may be discharged safely.2–12 None of these tools have been derived from or validated in a UK or Republic of Ireland population. In the USA, where many of these tools and guidelines were developed, consensus with regard to a universal approach to patients remains lacking.13
The aims of this study were to establish the current practice of ED management of syncope in the UK and Republic of Ireland, to investigate whether improved research-based guidelines are required and to evaluate what facilities are available in UK ED to which such guidelines could be tailored.
A questionnaire and accompanying letter was designed by the study authors (see the appendix available online only). An electronic list of all 312 ED in the UK and Republic of Ireland was obtained from the British Association for Accident and Emergency Medicine (BAEM) in September 2007. ED not listed as “major” or “intermediate” in the last BAEM directory were removed, leaving 254 ED. The questionnaire with a covering letter and a pre-paid return envelope was then sent out to a named consultant at each one of the 254 ED. After a month the questionnaire was resent to those ED that had not initially responded (157) this time addressed to “Nurse in charge”. Finally those ED that had not responded after two attempts (86) were telephoned (fig 1). This study was designed in accordance with published recommended guidelines for ED questionnaires.14 15
A total of 177 ED (70%) responded; 32 (18%) have syncope guidelines. Of these, six are based on the European Society of Cardiology guidelines,8 9 four on the American College of Emergency Physicians guidelines,12 six on the American College of Physicians guidelines,10 11 two on the OESIL syncope score,6 three on the San Francisco syncope rule4 5 and eight on “other”, usually an ED consultant personal opinion. Nine gave no response to this question and four guidelines are based on more than one source. Of the 32 ED with guidelines, 22 are in paper form, three are in poster format and 12 are in electronic form.
Of the 32 ED with syncope guidelines, 22 are for ED use only and six are general hospital guidelines. Table 1 shows the comparison of ED with and without syncope guidelines; 97 of 177 ED (55%) have an observation ward or clinical decision unit; 48 (49%) of these admit syncope patients to the unit. Thirty-two ED (18%) have access to a specialist syncope outpatient clinic; 28 of these 32 ED (88%) can access this clinic from the ED. Figure 2 displays which specialty runs this clinic. Seventy-eight ED (44%) have access to near-patient testing in their ED and eight (5%) use near-patient brain natriuretic peptide testing in their ED.
This is the first survey to describe the management of syncope in UK emergency medical practice. It clearly shows marked variation in routine practice in the UK and Republic of Ireland. We managed to achieve a 70% response rate to our questionnaire. This compares favourably with similar studies. There is no reason to suspect that these results are not generalisable to all medium and large size UK ED. It is of interest how few ED have syncope guidelines to assist decision-making given the complexity of risk stratification and disposition of this common ED presentation. Eighty-one per cent of ED felt that improved research-based guidelines would be of use when managing syncope patients. Although we did not specifically ask why guidelines were not used, these findings may suggest dissatisfaction with existing guidelines. It is our belief that the lack of a UK ED orientated guideline has led some ED to construct their own guidelines based on a variety of sources, whereas others simply have no advice in place. A consensus UK guideline similar to that published by the American College of Emergency Physicians is clearly required.
Eighteen per cent of ED have access to a specialised syncope clinic. This is more common in ED with existing guidelines. It is likely that in these ED, the clinic forms part of a structured pathway of care with the identification of low-risk patients safe to be discharged and medium-risk patients who may be able to go home with early follow-up and investigation. Many ED have an observation ward or clinical decision unit and many already admit syncope patients to this. There is clearly scope to manage syncopal patients in a similar way to other common conditions such as chest pain with a period of observation, along with risk stratification in the form of echocardiography and biochemical markers. Forty-four per cent of ED already use near-patient testing and 5% have access to near-patient brain natriuretic peptide, a biomarker currently undergoing investigation as a syncope biomarker.16
We suggest that once completed, the results from the ROSE study, the first UK emergency medicine specific clinical decision rule for the management of syncope, could be used to form the basis of a College of Emergency Medicine approved UK syncope guideline. We envisage that this guideline would utilise existing pathways sent to us from other services in the UK and Republic of Ireland. If the ROSE study safely identifies low-risk patients then a robust consensus guideline may also support the immediate discharge of certain patient groups who could receive further evaluation in specialist syncope outpatient clinics.
The ED management of syncope patients in the UK and Republic of Ireland is varied. Only 18% of ED have specific guidelines for managing this difficult and common condition and only 18% have access to a specialist syncope clinic.
The authors would like to thank the BAEM for allowing them to use their electronic ED list. Thank you to all ED who participated in this survey and to all those who managed to give a little bit of their time to complete and return the questionnaire.
Competing interests: None.
Funding: MR is receiving funding from a chief scientist office research fellowship (CSO/CAF/06/01).
▸ The appendix is published online only at http://emj.bmj.com/content/vol26/issue5
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.