1
|
Ebben RHA, Vloet LCM, Verhofstad MHJ, Meijer S, Groot JAJMD, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scand J Trauma Resusc Emerg Med 2013; 21:9. [PMID: 23422062 PMCID: PMC3599067 DOI: 10.1186/1757-7241-21-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/29/2013] [Indexed: 12/15/2022] Open
Abstract
A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.
Collapse
Affiliation(s)
- Remco HA Ebben
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, PO Box 6960, 6503 GL, Nijmegen, The Netherlands
| | - Lilian CM Vloet
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
- Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | | | - Sanne Meijer
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
| | - Joke AJ Mintjes-de Groot
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
| | - Theo van Achterberg
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| |
Collapse
|
2
|
Can Benign Etiologies Predict Benign Outcomes in High-Risk Syncope Patients? J Emerg Med 2011; 40:592-7. [DOI: 10.1016/j.jemermed.2009.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 08/04/2009] [Accepted: 09/20/2009] [Indexed: 11/20/2022]
|
3
|
Predicting adverse outcomes in syncope. J Emerg Med 2007; 33:233-9. [PMID: 17976548 DOI: 10.1016/j.jemermed.2007.04.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 01/05/2007] [Accepted: 04/05/2007] [Indexed: 11/24/2022]
Abstract
Syncope is a common presentation to the Emergency Department (ED); however, appropriate management and indications for hospitalization remain an ongoing challenge. The objective of this study was to determine if a predefined decision rule could accurately identify patients with syncope likely to have an adverse outcome or critical intervention. A prospective, observational, cohort study was conducted of consecutive ED patients aged 18 years or older presenting with syncope. A clinical decision rule was developed a priori to identify patients at risk if they met any of the following 8 criteria: 1) Signs and symptoms of acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical examination; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion; 8) Primary central nervous system event. The primary outcome was either a critical intervention or an adverse outcome within 30 days. Among 362 patients enrolled with syncope, 293 (81%) patients completed their 30-day follow-up. Of these, 201 (69%) were admitted. There were 68 patients (23%) who had either a critical intervention or adverse outcome. The rule identified 66/68 patients who met the outcome for a sensitivity of 97% (95% confidence interval 93-100%) and specificity of 62% (56-69%). This pathway may be useful in identifying patients with syncope who are likely to have adverse outcome or critical interventions. Implementation and multicenter validation is needed before widespread application.
Collapse
|
4
|
Reed MJ, Newby DE, Coull AJ, Jacques KG, Prescott RJ, Gray AJ. The Risk stratification Of Syncope in the Emergency department (ROSE) pilot study: a comparison of existing syncope guidelines. Emerg Med J 2007; 24:270-5. [PMID: 17384381 PMCID: PMC2658233 DOI: 10.1136/emj.2006.042739] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS This study was conducted as a feasibility pilot for the Risk stratification Of Syncope in the Emergency department (ROSE) study. The secondary aim was to compare the performance of our existing emergency department (ED) guidelines with existing clinical decision rules (Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) Score and San Francisco Syncope Rule; SFSR) at predicting short-term (1 week and 1 month) and medium-term (3 months) serious outcomes for patients with syncope presenting to the ED. METHODS This was a prospective cohort study. All patients presenting with syncope aged > or = 16 years between 7 November 2005 and 7 February 2006 were prospectively enrolled. RESULTS 99 patients were recruited over a 3-month period. 44 patients were admitted and 55 discharged from the ED. 11 patients had a serious outcome: 8 by 7 days and a further 3 by 3 months. Five patients died by 3 months and six others had an alternative serious outcome. All 11 patients had been admitted from the ED, 7 were at high risk, 4 were at medium risk and none were at low risk according to our existing ED guidelines. Percentages of serious outcomes were 0%, 2.9%, 8.0%, 22.7% and 37.5% for OESIL scores of 0, 1, 2, 3 and 4 respectively. 40 patients had none of the 5 SFSR high-risk factors (0 serious outcomes = 0%) and 59 patients had an SFSR high-risk factor (11 serious outcomes = 18.6%). The risk of serious outcome at 7 days, 1 month and 3 months was 8.1%, 8.1% and 11.1%, respectively. CONCLUSIONS A study to derive and validate a UK ED syncope clinical decision rule is feasible. This pilot study has evaluated the OESIL score, the SFSR and our existing ED guidelines, and has shown that each is able to identify an increased probability of medium-term serious outcome in patients with syncope. The SFSR shows good sensitivity at the expense of an increase in admissions to hospital; however, our existing ED syncope guidelines and the OESIL Score, although being able to successfully risk stratify patients, are not sufficiently sensitive to be able to reduce admissions without missing patients at risk of a serious outcome. Undoubtedly there is a need for a simple UK-derived clinical decision rule for patients presenting with syncope to enable safe, effective clinical care and to aid less experienced decision makers.
Collapse
Affiliation(s)
- Matthew J Reed
- Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
| | | | | | | | | | | |
Collapse
|
5
|
Reed MJ, Gray A. Collapse query cause: the management of adult syncope in the emergency department. Emerg Med J 2007; 23:589-94. [PMID: 16858087 PMCID: PMC2564156 DOI: 10.1136/emj.2005.032136] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Syncope is a commonly encountered problem in the emergency department (ED). Its causes are many and varied, some of which are potentially life threatening. A review was carried out of relevant papers in the available literature, and this article attempts to assimilate current evidence relating to ED management. While the cause of syncope can be identified in many patients, and life threatening conditions subsequently treated, a risk stratification approach should be taken for those in whom a cause is not identified in the ED. Aspects of the history and examination that may help identify high risk patients are explored and the role of investigations to aid this stratification is discussed. Identifying a cardiac cause for syncope is a poor prognostic indicator. Patients with unexplained syncope who have significant cardiac disease should therefore be investigated thoroughly to determine the nature of the underlying heart disease and the cause of syncope, although presently there is little evidence that this improves their dismal prognosis. This risk stratification approach has led to the development of several clinical decision rules, which are discussed along with current international guidelines on syncope management. This review suggests that presently the American College of Emergency Physicians guidelines are the most useful aids specific to the management of syncope in the ED; however, the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score may also be a useful ED risk stratification tool.
Collapse
Affiliation(s)
- M J Reed
- Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
| | | |
Collapse
|
6
|
Suzuki M, Hori S, Aikawa N. Application of the Recent American Practice Resources for Risk Stratification System for Patients Presenting to a Japanese Emergency Department Because of Syncope. Int Heart J 2007; 48:513-22. [PMID: 17827823 DOI: 10.1536/ihj.48.513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The American College of Physicians (ACP) and the American College of Emergency Physicians (ACEP) recently published practice guidelines and recommendations for evaluation of patients with syncope based on historical, physical, and ECG findings. The objective of the present study was to determine if risk stratification using these practice resources is valid in a series of Japanese patients. METHODS AND RESULTS A total of 912 consecutive patients brought to our emergency department between 1988 and 1997 because of syncope were identified. Follow-up information about mortality was obtained for 707 patients by means of mailed questionnaires and from medical records, and the mortality data were analyzed by the actuarial life-table method. A total of 187 patients who fulfilled the admission criteria according to the ACP guidelines were found to have higher overall and cardiac mortality than the other 520 patients (P < 0.0001), and 153 patients who fulfilled the admission criteria according to the ACEP recommendations also had higher overall and cardiac mortality than the other 554 patients (P < 0.0001). CONCLUSIONS The recent American practice recommendations can be used for risk stratification of syncope patients in Japan. Historical, physical, and ECG findings available on presentation can be used to stratify the risk of mortality in patients brought to Japanese emergency departments because of syncope.
Collapse
Affiliation(s)
- Masaru Suzuki
- Department of Emergency Medicine, Keio University, Tokyo, Japan
| | | | | |
Collapse
|
7
|
Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med 2006; 47:448-54. [PMID: 16631985 DOI: 10.1016/j.annemergmed.2005.11.019] [Citation(s) in RCA: 175] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Revised: 11/01/2005] [Accepted: 11/07/2005] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE We prospectively validate the San Francisco Syncope Rule (history of congestive heart failure, Hematocrit <30%, abnormal ECG result [new changes or non-sinus rhythm], complaint of shortness of breath, and systolic blood pressure <90 mm Hg during triage). METHODS In a prospective cohort study, consecutive patients with syncope or near syncope presenting to an emergency department (ED) of a teaching hospital were identified and enrolled from July 15, 2002, to August 31, 2004. Patients with trauma, alcohol, or drug-associated loss of consciousness and definite seizures were excluded. Physicians prospectively applied the San Francisco Syncope Rule after their evaluation, and patients were followed up to determine whether they had had a predefined serious outcome within 30 days of their ED visit. RESULTS Seven hundred ninety-one consecutive visits were evaluated for syncope, representing 1.2% of all ED visits. The average age was 61 years, 54% of patients were women, and 59% of patients were admitted. Fifty-three visits (6.7%) resulted in patients having serious outcomes that were undeclared during their ED visit. The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events. In this cohort, the San Francisco Syncope Rule classified 52% of the patients as high risk, potentially decreasing overall admissions by 7%. If the rule had been applied only to the 453 patients admitted, it might have decreased admissions by 24%. CONCLUSION The San Francisco Syncope Rule performed with high sensitivity and specificity in this validation cohort and is a valuable tool to help risk stratify patients. It may help with physician decisionmaking and improve the use of hospital admission for syncope.
Collapse
Affiliation(s)
- James Quinn
- Division of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | | | | | | | | |
Collapse
|
8
|
Sun B, Camargo C. Syncope and NAMCS - In Reply. Acad Emerg Med 2005. [DOI: 10.1197/j.aem.2004.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
9
|
Sun BC, Emond JA, Camargo CA. Characteristics and Admission Patterns of Patients Presenting with Syncope to U.S. Emergency Departments, 1992–2000. Acad Emerg Med 2004. [DOI: 10.1111/j.1553-2712.2004.tb00673.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Sun BC, Emond JA, Camargo CA. Characteristics and admission patterns of patients presenting with syncope to U.S. emergency departments, 1992-2000. Acad Emerg Med 2004; 11:1029-34. [PMID: 15466144 DOI: 10.1197/j.aem.2004.05.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To describe the characteristics and admission patterns of patients with syncope presenting to U.S. emergency departments (EDs). METHODS The ED portion of the National Hospital Ambulatory Medical Care Survey, 1992-2000, was analyzed. Nationally representative weighted estimates for incidence and admission rates were estimated and stratified by demographic variables. Presence of cardiovascular diagnoses on ED discharge was noted. RESULTS Of the 865 million ED visits during the nine-year study period, an estimated 6.7 million (0.77%; 95% confidence interval [95% CI] = 0.69% to 0.85%) were related to syncope. Higher incidences of ED visits for syncope were found in elder, female, and non-Hispanic patients compared with their reference groups. The overall admission rate was 32% (95% CI = 28% to 36%). Older, male, and white patients were admitted more frequently than their counterparts. Of patients older than 80 years of age, 58% (95% CI = 49% to 67%) were admitted. Associated cardiovascular International Classification of Diseases, Ninth Revision (ICD-9), codes for ischemic, structural, and arrhythmic heart disease were noted in 10% (95% CI = 8% to 13%) of patients, and 66% (95% CI = 56% to 76%) of these patients were admitted. CONCLUSIONS Syncope is a frequent reason for ED visits and admissions. Elders and patients with associated cardiovascular diagnoses are frequently discharged, and admission practices appear to deviate from consensus panel guidelines.
Collapse
Affiliation(s)
- Benjamin C Sun
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | | | | |
Collapse
|
11
|
Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med 2004; 43:224-32. [PMID: 14747812 DOI: 10.1016/s0196-0644(03)00823-0] [Citation(s) in RCA: 257] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE The causes of syncope are usually benign but are occasionally associated with significant morbidity and mortality. We derive a decision rule that would predict patients at risk for short-term serious outcomes and help guide admission decisions. METHODS This prospective cohort study was conducted at a university teaching hospital and used emergency department (ED) patients presenting with syncope or near syncope. Physicians prospectively completed a structured data form when evaluating patients with syncope. Serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event) were defined at the start of the study. All patients were followed up to determine whether they had experienced a serious outcome within 7 days of their ED visit. Univariate analysis was performed with chi2 and nonparametric techniques on all predictor variables. kappa Analysis was performed on variables requiring interpretation. Variables with kappa more than 0.5 and a P value less than.1 were analyzed with recursive partitioning techniques to develop a rule that would maximize the determination of serious outcomes. RESULTS There were 684 visits for syncope, and 79 of these visits resulted in patients' experiencing serious outcomes. Of the 50 predictor variables considered, 26 were associated with a serious outcome on univariate analysis. A rule that considers patients with an abnormal ECG, a complaint of shortness of breath, hematocrit less than 30%, systolic blood pressure less than 90 mm Hg, or a history of congestive heart failure has 96% (95% confidence interval [CI] 92% to 100%) sensitivity and 62% (95% CI 58% to 66%) specificity. If applied to this cohort, the rule has the potential to decrease the admission rate by 10%. CONCLUSION The San Francisco Syncope Rule derived in this cohort of patients appears to be sensitive for identifying patients at risk for short-term serious outcomes. If prospectively validated, it may offer a tool to aid physician decision making.
Collapse
Affiliation(s)
- James V Quinn
- Division of Emergency Medicine, University of California-San Francisco, San Francisco, CA 94304, USA.
| | | | | | | | | | | |
Collapse
|
12
|
Sun BC, Emond JA, Camargo CA. Inconsistent electrocardiographic testing for syncope in United States emergency departments. Am J Cardiol 2004; 93:1306-8. [PMID: 15135712 DOI: 10.1016/j.amjcard.2004.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2003] [Revised: 02/02/2004] [Accepted: 02/02/2004] [Indexed: 11/28/2022]
Abstract
The electrocardiogram has diagnostic and prognostic value in the evaluation of syncope, and consensus guidelines suggest routine electrocardiographic testing. An analysis of a nationally representative survey suggests that electrocardiographic testing is performed inconsistently in patients presenting with syncope to United States emergency departments, even in high-risk patients, such as the elderly and hospitalized. Variation in electrocardiographic testing represents an opportunity to improve the care of patients presenting with syncope to emergency departments.
Collapse
Affiliation(s)
- Benjamin C Sun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02115, USA.
| | | | | |
Collapse
|