Venkatesh Thiruganasambandamoorthy: Multi-Center Cluster-Randomized Implementation of Canadian Syncope Risk Score based Practice Recommendations for Emergency Department Syncope Management

Syncope is a sudden transient loss of consciousness (LOC) followed by spontaneous complete recovery, accounts for 1-3% of emergency department (ED) visits, and up to 6% of admissions from the ED. Among ED syncope patients, approximately 10% will have suffer serious outcomes [e.g. arrhythmia, or non-arrhythmia (myocardial infarction, significant hemorrhage, pulmonary embolism); or die] within 30 days. One-third to half of these serious conditions will be identified after ED disposition. We previously enrolled 8176 patients over 92 months at 11 Canadian hospitals to derive and validate the Canadian Syncope Risk Score (CSRS) that predicts the 30-day serious outcome probability after ED disposition. In this study, overall 0.5% died and 0.3% suffered ventricular arrhythmia. Currently, wide variations in ED management [investigations, length of stay (LOS) and hospitalizations (4.1% – 17.1%)] exist and among those hospitalized, a significant proportion (46.5%) were hospitalized for suspected arrhythmias. Using the results and with input from all physicians involved in syncope care, knowledge translation (KT) experts and patients, we have developed practice recommendations incorporating the CSRS. At the end of their ED visit if no serious underlying conditions are identified: low-risk can be discharged without further interventions and brief hospitalization can be considered for high-risk patients. Medium and high-risk discharged from the ED will benefit from out-of-hospital external cardiac rhythm monitoring for 15 days. We have identified modifiable barriers for successful implementation such as better education of the physicians on the CSRS, access to monitoring devices and timely outpatient follow-up of patients after ED discharge. 

Objective: The overall aim is to improve ED syncope care by reducing health care resource utilization (hospitalization and ED LOS), and morbidity and mortality by appropriate identification of those at higher risk. Methods: We will conduct a stepped wedge cluster randomized trial at 21 Canadian EDs to enroll adult ED syncope patients after consent. All sites will go through a pre-implementation phase (usual care), receive educational intervention on CSRS based practice recommendations and randomly transition over a one-month period (first month designated as transition period) in a stepwise fashion to post-implementation phase. Implementation will involve local champions, address the barriers/enablers identified, robust knowledge translation (through educational activities-presentations, webinars) and access to the recommendations, and audit and feedback at the site and physician levels. Data collection: We will collect data on ED management including LOS, hospitalization, recommendation adherence and reasons for overriding, and 30-day serious outcomes. Outcomes: Primary outcomes will be ED LOS defined as the time to ED disposition decision after the start of physician assessment. Secondary outcomes include hospitalization, 30-day serious outcomes after ED disposition, and recommendations adherence. Data analysis: We will use intention to treat principle. Sample size: At the end of the implementation phase, we hope to achieve a 30% reduction in ED LOS and calculated 9000 patients will be needed be enrolled at 21 sites (18 clusters) over 23 months. End of grant KT plan will evaluate interventions and its behavioral change effect to develop a widespread dissemination plan.