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Topic Syncope represents around 1% of all ED attendances (Quinn J et al, Ann Emerg Med. 2006,47(5):448-54). Owing to syncope's wide range of pathologies, inappropriate admissions and investigations are commonplace. The European Society of Cardiology (ESC) Syncope guidelines provide a key tool to guide appropriate admissions and investigations.
Intervention We performed a chart review of all patients admitted to a Regional Hospital over a four-week period for the work-up of syncope. By applying the ECS guidelines we evaluated the appropriateness of these admissions and the ensuing investigations. We then provided an education session on the guidelines to the admitting medical doctors and provided easy access to these guidelines while on call before re-auditing.
Improvement During the initial chart review 44% (7/16) of admissions were inappropriate, the average length of stay for these inappropriate admissions was 2 days. Brain imaging was performed in 62.5% (10/16) of those admitted – this was inappropriate in 70% (7/10). Cardiac investigations were largely appropriate. Only 40% had lying and standing blood pressures as part of their bedside investigations. In the re-audit the ESC guidelines were complied with in 100% (10/10) of admissions. 80% had bedside lying and standing blood pressures. 50% (2/4) of the CT brains ordered in the re-audit were inappropriate.
Discussion This audit demonstrates that the minimal cost intervention of education sessions and making the ESC guidelines easily accessible to the medical staff has the potential to reduce inappropriate syncope admissions. With an average cost of stay for non-elective inpatients of £1,542 (Department of Health, NHS Reference costs, 2014, 2013-2014:1-58) and average CT scan unit cost of £121 (National Audit Office, Report by the Comptroller and Auditor General, 2011, HC 822, 1-38), these interventions could have led to a potential reduction in spend on syncope admissions of £11,399 in this small initial sample. This is in addition to the benefits to patients of avoiding hospital admission and harm from inappropriate investigations. Further improvements in inappropriate brain imaging and use of simple bedside investigations are needed.