ESC Syncope Guidelines implementation

The ESC Syncope Guidelines were implemented in the ED to structure the evaluation of suspected syncope in a stepwise manner: (1) recognition of TLOC and differentiation between syncope and non-syncopal TLOC, (2) initial syncope evaluation (i.e. structured history taking, physical examination, supine and upright blood pressure measurements and a 12-lead ECG) and (3) risk stratification in those without a certain or highly likely diagnosis (1). Management strategies differed by risk (1). Those with low-risk criteria only were discharged home or referred to the general practitioner; those with any high-risk factor for cardiac syncope were evaluated by a cardiologist in the ED; those with intermediate risk could be referred to the syncope unit or admitted for further evaluation, which choice was left to clinical judgement. Syncope unit referral was also recommended for those with intermediate risk following an uneventful clinical observation period or for those with exclusively low-risk features but recurrent and incapacitating syncopal events.

Prior to the intervention period, no participating hospital had implemented the ESC Syncope Guidelines in the ED, and none of the EDs referred to a multidisciplinary syncope unit. Pre-intervention syncope care differed between sites. The primary evaluation was performed by emergency physicians or cardiologists (Leiden University Medical Centre, Diakonessenhuis Utrecht and Rijnstate Hospital), internists specialised in acute medicine or cardiologists (Maasstad Hospital), or internists, cardiologists or neurologists (Gelre Hospital). In all centres, patients were primarily seen by a resident supervised by a specialist.

We organised teaching sessions of 2 h explaining the ESC guidelines as part of the implementation. These sessions were aimed at all residents and specialists involved in syncope care in the ED and were repeated at least three times in each hospital to ensure that all relevant personnel could take part. Flash cards with ESC Syncope Guidelines flowcharts were distributed among the ED staff. Sessions were presented by a syncope specialist (SYGP or other medical specialists with expertise in syncope and knowledge of ESC syncope guidelines). New residents starting work at the ED during the study were educated individually. Nurses, technicians and medical specialists working at the syncope unit attended a 1-day course at the Leiden University Medical Centre. All centres adhered to the EFAS/European Academy of Neurology protocol for tilt testing [30].