© 2005 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
Prospective evaluation of an educational programme for physicians involved in the management of syncope
Department of Cardiology, Hôpital de la Cavale Blanche, Brest University Hospital Boulevard Tanguy Prigent, 29609 Brest Cedex, France
Manuscript submitted 15 January 2005. Accepted after revision 17 March 2005.
*Corresponding author. Tel.: +33 2 98 34 73 92; fax: +33 2 98 34 78 03. E-mail address: jean-jacques.blanc{at}univ-brest.fr (J.-J. Blanc)
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Abstract |
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AIM: Management of patients (pts) presenting syncope diverges markedly from the guidelines of the European Society of Cardiology (ESC). To improve this management, the easiest option seemed to be to educate physicians. The aim of the study was to evaluate the impact of an educational process on the use of unnecessary neurological investigations.
METHODS AND RESULTS: Charts of pts presenting syncope during two 12-month periods (1999–2000 and 2002–2003) to the emergency department were systematically reviewed. Between the two periods, all physicians in charge of pts with syncope attended educational meetings. During these meetings recommendations of the ESC were presented with a special emphasis on the uselessness of neurological investigations.
Four hundred and fifty-four pts (1.2%) presented to the emergency department for syncope during study period 1, and 524 (1.3%) during study period 2. Nineteen of the 169 pts (11%) directly discharged from the emergency department, had neurological investigations during study period 1 and 22 of the 279 (8%) during study period 2 (NS). In pts who were hospitalized, 48% had neurological investigations in groups 1 and 2.
CONCLUSION: Education of physicians in charge of patients with syncope is inadequate to improve the cost effectiveness of the management of these patients.
Key Words: syncope, epidemiology, education
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Introduction |
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Syncope is one of the most common causes of presentation to the emergency department. Twenty years ago in the USA, its incidence was estimated at 3% [1–
3]. More recently the percentage of patients attended urgently at general or university hospitals for syncope in European countries was reported at 1% [4–7]. However, the management of patients with syncope diverged markedly from one department to another [4], from one hospital to another [7] and more importantly from the recommendations recently published by the European Society of Cardiology [8,9]. This lack of uniform strategy leads to a limitation in the number of diagnoses [4] and to an undue increase in costs [6]. Improvement in the management of patients with syncope is, therefore, a crucial issue. Implementation of an educational process of physicians in charge of patients with syncope has not been extensively evaluated and this was the main end point of this study. |
Methods |
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Definition
Syncope was defined in the present study according to the guidelines of the European Society of Cardiology [8]
. Definition of this symptom is widely accepted [10,11] and is the same as that used in previous trials [4]. Syncope is defined as a transient, self-limited loss of consciousness associated with an inability to maintain postural tone and not compatible with other states of altered consciousness (seizure, coma,...). The onset of syncope is relatively rapid, and the subsequent recovery spontaneous, complete, and usually prompt.
Patient inclusion process
The process by which patients were included in our evaluation of the epidemiology of syncope in our hospital has been previously described in detail [4]. This process remained unchanged. In brief, the chart of every patient admitted to the adult emergency department of the Brest University Hospital was reviewed by one member of staff of the Cardiology Department. Patients directly admitted to a medical department for evaluation of syncope were excluded. Decision to admit a patient to a department of the hospital from the emergency department was left to the discretion of the physician(s) on duty.
The recruitment process was performed by consulting the charts of all the patients who attended the emergency room in the previous 24 h. Those with a loss of consciousness corresponding to the definition of syncope were eventually included. Those with other symptoms (dizziness, panic disorders, seizure, vertigo, falls, transient ischaemic attack, intoxication,...) were excluded. If the diagnosis of syncope remained uncertain, the patients, and when possible their family were contacted and after discussion the diagnosis was confirmed or not.
For hospitalized patients charts were reviewed after discharge with the informed consent of the chief of every department; investigations performed and the final diagnoses were carefully collected.
Differences between the two studies
In the study conducted from June 1999 to June 2000 (study 1) we did not promote any standardized practice and it could be considered as a baseline observational study [4]. In the subsequent, present study (study 2) all physicians in charge of patients with syncope, identified after the first study were contacted, several times if necessary, to attend one meeting. During this meeting the results of the first study were presented and extensively discussed with regard to the different investigations performed. Recommendations of the European Society of Cardiology [8] were explained with special emphasis on the uselessness of neurological imaging investigations (except in the case of incidental head trauma which legitimizes head imaging), the incompatibility of some diagnoses as causes of syncope (for example hypoglycaemia or transient ischaemic attacks) and for the physicians in charge of the emergency department, when to hospitalize. Flow charts of the guidelines were provided and it was advised to call, in case of difficulty, physicians of the Cardiology Department. Furthermore, one physician of the emergency department attended a two-day meeting at the European Heart House in October 2002 devoted to recommendations for syncope. All these actions took place, except the last during the calendar year 2001 and we left a delay of several months between the last meeting and the beginning of the present study which was prospectively conducted from April 2002 to April 2003. This delay was deliberately allowed to evaluate the long-term effects of education. In order clearly to differentiate the effects of education from those of another organizational process (the so called "syncope unit") physicians were not required to follow a strict standardized strategy but to apply what they had learnt.
End points
The main objective of the present study was to evaluate in a prospective fashion the effectiveness of the above-mentioned actions on the management of patients presenting with syncope to the emergency department and subsequently, if the patient was hospitalized in other medical departments. Considering that neurological imaging examinations were frequently prescribed in the first prospective registry while they are considered useless in the diagnostic management of patients with syncope [8] we expected a significant decrease in their prescription rate would represent a relevant end point for the educational process.
Statistical analysis
Data are presented as mean ± standard deviation. Comparison of continuous and nominal variables was performed by the Student t-test or the 
2 test, respectively. Differences in the percentage between the two study periods were considered to be statistically significant when the P value was <0.05.
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Results |
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During the 1-year study period beginning from April 2002, 39,838 patients were presented to the emergency department. Among these patients 524 (1.31%) were considered to have syncope according to our inclusion criteria. The majority were women (310 or 59%) and the mean age of the group was 58 ± 25 years, without significant difference between men (57.5 years) and women (59.4 years). For 438 patients it was the first episode (83.6%) while 86 (16.4%) reported a previous syncope: in 45 cases the first episode occurred during the preceding year (22 had one, 13 had between two and five and 10 had more than five) and within more than 1 year in 33 cases (one previous episode in 14 cases and more than one in 19 cases). As summarized in Table 1 comparison of the epidemiological data observed between the two study periods were very similar; the only noticeable difference, without satisfying explanation concerned the percentage of first episodes which were more frequently observed in the second period (P < 0.0001).
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Management in the emergency department |
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A majority of patients was directly discharged from the emergency department (279 or 53%). For those who were hospitalized, the department where they were admitted is reported in Table 1. Internal medicine received more than 50% of the patients; neurology and cardiology accepted each between 15% and 17%, surgery 9%. As already observed in our previous study, the patients directly discharged were significantly (P < 0.0001) younger (51 ± 25 years) than those hospitalized (68 ± 20 years). All the patients, admitted or discharged had a complete physical examination, an electrocardiogram and baseline screening laboratory tests. Among the 279 discharged patients, 34 had either during their stay in the emergency department or in the following days additional examinations: head CT scan in 13 (5%), electroencephalography in eight (3%), lumbar puncture in one, carotid Doppler in one, echocardiography in four, Holter monitoring in five and tilt testing in two. Furthermore, 17 patients were advised to consult subsequently a cardiologist, four a neurologist, five a psychiatrist and 45 their general practitioner. The most common diagnosis for the patients directly discharged was vasovagal syncope (159 cases or 57%); the second most frequent diagnosis was orthostatic hypotension (12 cases or 4%). Of interest, the diagnosis of hypoglycaemia reported in 8% of patients in study 1 was found in only 2% in study 2 (P < 0.0001). Finally 71 patients (25%) left the emergency room without a diagnosis and only a minority was advised to have further examinations or consultations. This did not include the nine patients with a diagnosis compatible with syncope.
When compared with study 1 the following modifications in the management of patients in study 2 in the emergency department were observed (Table 2): significantly more patients were discharged directly and more patients were advised to have additional examinations and visits especially to cardiology (from 2.4% to 6.1%, p = 0.01). On the other hand many data remained unchanged, particularly the distribution of patients in different departments, the percentage of neurological investigations performed and the percentage of patients who left the emergency room without a diagnosis.
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In-hospital management |
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The mean hospital stay (Table 1) varied according to the department: shorter stays were observed in cardiology (P < 0.0001 in comparison with internal medicine and neurology). When compared with study period 1 stays (Table 1) in neurology and cardiology but not in internal medicine had a propensity to be shorter during study period 2. The different examinations performed during the hospital stay are listed in Table 3. Investigations performed during hospitalization were mainly neurological: head CT scan in 69 cases (28%) and electroencephalograms in 49 cases (20%). These values are in the same range as the values observed in the previous study. Neurological investigations were almost routine in neurology (46 examinations performed in 37 patients) and frequent in internal medicine (56 examinations performed in 124 patients) but rare in cardiology (four examinations performed in 41 patients). Interestingly, the proportion of neurological investigations increased between the two study periods in neurology (from 59% to 124%) but decreased in internal medicine (from 54% to 45%) and in cardiology (from 18% to 10%) although neurologists had the same training.
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Diagnosis |
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Among the 524 patients in the second study, 379 (72.3%) were considered to have an explanation for their syncope (Table 4). This value is comparable with the one observed in study 1 (75.7%). However, as in study 1, but less frequently (from 16.3% to 5.3%) some diagnoses could explain a loss of consciousness but not syncope as defined above. The most common cause of these inappropriate diagnoses is transient ischaemic attacks (nine cases) and hypoglycaemia (eight cases). When these inappropriate diagnoses are added to the "non-diagnostic" group, a total of 173 patients (33%) left the hospital without a clear diagnosis. This feature is in the same range as that observed in study 1 (36.6 %).
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Discussion |
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The major finding of the present study, considering the main end point was that management of patients with syncope evolved positively in the emergency department but remained unchanged in other departments.
Emergency room management
The percentage of all neurological investigations (head CT scan and electroencephalography) decreased but only slightly (from 11.2% to 7.6%). It could be hypothesized that this reduction in useless and costly examinations [6,8] for patients with syncope (except for a very limited number of patients with severe head trauma) is the consequence of the educational sessions especially dedicated to physicians on duty in the emergency rooms. This opinion is reinforced by the observation that during the stay in the emergency department patients were more frequently advised to make visits to other physicians and particularly to cardiologists. However, these improvements, although real, remained limited and could not be considered as a substantial change in the management of patients with syncope. This inadequate and costly management explains, probably, why a significant number of patients left the emergency room without a diagnosis and without counselling or with a diagnosis totally unable to explain a syncopal episode. However, it should be stressed that the proportion of these inadequate diagnoses, particularly hypoglycaemia, diminished.
Finally, the emergency room management of patients with syncope is currently more in agreement with the guidelines reported by the European Society of Cardiology [8] than 3 years ago [4] but still remains far from optimal.
In-hospital management
Although almost 75% of the patients were discharged with a diagnosis, this was certainly unable to explain a syncopal episode in a substantial number of patients (5.2%). This does not mean that the cause of the syncope was certainly correct in the remaining cases but that it was plausible to explain syncope. The in-hospital management, however, remained strictly unchanged when compared with the management observed in the study 1 [4]. Particularly the neurological investigations and especially CT head scans were performed in the same proportion of patients and in the same departments (neurology and internal medicine). This failure of the educational process may be explained by: insufficient information, physicians not concerned, new physicians who had not attended educational meetings.... Whatever the cause, the fact is that the educational process had been insufficiently effective in these groups of physicians.
Epidemiological data
In comparing the two study periods, we did not observe significant changes in the main epidemiological findings. Although the number of patients presenting to the emergency department increased the proportion of patients with syncope remained unchanged (1.21% in group 1 and 1.31% in group 2, 3 years later). The predominance of females was found in the two groups and the mean age was similar.
Was the end point appropriate?
We had chosen as main end point the effectiveness of education on the evolution of neurological investigations. This was based on the fact that recommendations of the European Society of Cardiology stated that except in patients with head trauma these investigations are totally useless and that they were frequently performed in group 1. Furthermore, it was relatively easy to stress this point during the meetings with physicians and finally this parameter is measurable. Other data such as percentage of diagnoses, "false" diagnoses... might have been chosen but they are more subjective and then more difficult to quantify.
Diagnoses
In the two study periods neurally-mediated syncope represented almost half of the diagnoses (48% in study 1 and 46% in study 2). Other reported diagnoses were cardiac arrhythmias (a relatively low proportion), structural cardiac disease, and autonomic failure. Finally, the proportion of patients leaving the hospital with a plausible diagnosis remained in the range of 2/3 in the two groups, a ratio certainly frustrating for physicians and patients.
How to improve the management?
Our educational process although partially effective has been slow and at this point incomplete. The Oesil study [12] has reported more positive results, the end point being the percentage of diagnoses "correctly" made for patients leaving the hospital after attending the emergency department. This resulted from the implementation of a very strict supervised management based on a flow chart. However, this was observed over a very short period of time (2 months) and it remains questionable whether this flow chart would have been followed for a longer time. The second option is based on so called "syncope units". They have been reported in a limited number of centres and in preliminary experience to improve the management of patients with syncope and to reduce significantly the cost [13,14].
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Conclusion |
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This study gives two main conclusions. Epidemiological data of patients admitted for syncope in the same hospital after a 3-year interval are identical allowing an evaluation of the impact of preventive actions. The educational process of physicians in charge of patients with syncope was disappointing to improve significantly the cost effectiveness of the management of these patients. However, there were some trends in favour of better management particularly in the emergency department. More effective teaching techniques associated with computer-based decision processes could convert these trends into more notable improvements.
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References |
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