Grant: Project Grant

Syncope (fainting) is a common problem with 160,000 patients visiting Canadian emergency departments (ED) annually. About 16,000 (10%) will have serious underlying problems (blood clots in the lung, heart attack, irregular heart rhythm requiring pacemaker/defibrillator) and/or will die; one-third to half of these serious conditions will not be evident during the initial ED visit. Enrolling 8176 patients at 11 Canadian hospitals, we derived and validated a robust tool, the Canadian Syncope Risk Score (CSRS). With qualitative interviews of 41 physicians (ED, cardiology, and hospitalists) and 35 patients at 12 Canadian hospitals, we developed the Canadian Syncope Pathway: if no serious conditions are found during the ED visit, we recommend low-risk patients be discharged with family physician follow-up as needed, medium-risk patients discharged with a clear discussion about outcome risk, and brief hospitalization for high-risk patients. Medium and high-risk patients discharged will benefit from 15-day external heart rhythm monitoring. We have identified modifiable barriers for implementation: improved education of doctors about the tool, availability of monitoring devices and timely follow-up. The goal of this study is to assess the effectiveness of the pathway's implementation by enrolling 11,520 syncope patients over 16 months at 16 cluster hospitals on healthcare efficiency and patient safety. Our intervention includes local champions, robust education, easy online access to materials, and incorporation of the pathway into electronic health records. We will assess the effect on hospitalization, time to disposition decision from physician initial assessment, consultations in the ED, 30-day serious outcomes; 1-year deaths, cardiac device insertions, ED visits, and hospitalizations; and process measures such as reach, adoption, and adherence to the recommendations. We hope to reduce the hospitalizations by 5% (currently 20.1%) while improving patient safety.