Abstract
Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.
Highlights
Syncope is a common yet complex presenting symptom and requires thoughtful and efficient evaluation to determine its etiology
1% to 3% of all emergency department (ED) visits, as many as atrial fibrillation, and up to 6% of all hospital admissions are due to syncope [1,4,5]
Survey results revealed that overall attitude toward evidence-based practices was moderate, and implementation of new guidelines were seen as a burden, potentially decreasing the likelihood of compliance
Summary
Syncope is a common yet complex presenting symptom and requires thoughtful and efficient evaluation to determine its etiology. Estimates indicate that one-half of all Americans will experience loss of consciousness during their lives, with recurrence rates as high as 13.5% [1]. 1% to 3% of all emergency department (ED) visits, as many as atrial fibrillation, and up to 6% of all hospital admissions are due to syncope [1,4,5]. Though vasovagal reflex-mediated syncope and orthostatic hypotension are the two most common types with benign courses [6], a cardiac etiology of syncope is associated with significantly higher rates of morbidity and mortality [3]. The QoL among patients with recurrent syncope appears equivalent to those with severe rheumatoid arthritis or chronic lower back pain [10]. One 2017 article showed that, after adjusting for inflation, the median hospital charge for a single admission for syncope increased by 1.5 times from the preceding decade [16]
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