LIHN

Copyrighted 2010

Syncope

Quality Measures Length of Stay

RCC Costs per Case

Critical Events

Evaluation Phase

Comprehensive History & Physical Exam

VS including orthostatic blood pressure

Labs based on history

ECG

Documentation of screening for pneumococcal & influenza (seasonal) vaccine

VTE (DVT) risk assessment

Appropriate VTE(DVT) prophylaxis if applicable

Medication reconciliation addressed

Baseline pain assessment

Progressive Phase

Smoking cessation advice/counseling if indicated

Testing completed and reported

Administration of pneumococcal/influenza (seasonal) vaccine if eligible

Discharge Day

Medication reconciliation addressed

Assess understanding of discharge instructions

Syncope Guideline

LIHN

Copyrighted 2010

Evaluation / Acute Phase

Assessment &

Consultation

Complete Day 1

Comprehensive history and physical**P

Baseline skin assessment and documentation of

present on admissionP,N

Baseline pain assessment** N

VTE(DVT) risk assessment **P,N

VS including orthostatic blood pressures**N

Physician Cardiac and Neurological Screening if

indicatedP

Admission assessment including smoking historyN

Initiate plan of careP,N

Fall / Risk assessmentP,N

MRSA/VRE screen if indicatedN

Documentation of screening for pneumococcal /

influenza (seasonal) vaccine**N

Education Complete Day 1

Assess barriers to learningP,N

Orientation to environment, safety protocolsN

Infection control procedures/ protocolsP,N

Medication teaching as appropriateN

Explain all tests, procedures, plan of care and

expected length of stayP,N

Tests

Complete Day 1

Labs based on history**

Consider ECHO (report on chart day 2)

ECG*

Consider cardiac enzymes

Drug levels as indicated

Avoid routine carotid duplex & EEG

Stool guiac x1

Treatments Cardiac Likely- Cardiac Monitoring

IV /Tubes/Drains IV / IV access

Medications Complete Day 1

Medication Reconciliation addressed**P,N

Appropriate VTE(DVT) prophylaxis if

applicable**

Medications as indicated

Diet & Elimination Diet As Ordered - Advance As ToleratedP,N,D

Intake & Output if indicatedN

Monitor and document bowel and bladder

eliminationN

Activity Ambulate as toleratedN, T-p

Discharge Planning /

Pyschosocial

Assess support networkN,CM,SW

Initiate discharge plan including appropriate

referralsN,CM,SW

Patient Outcomes Safety maintained

Assessments completed

Acceptable patient comfort level

Patient &/or family aware of plan of care

** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist

N = Registered nurse CM = Case Manager

Ph = Pharmacist SW = Social Worker

T-r = Respiratory Therapist T-p = Physical Therapist

Syncope Guideline

LIHN

Copyrighted 2010

Progressive Phase

Assessment &

Consultation

Reassessment of response to treatment and patient careP,N

Monitor effects of medication and assess for adverse drug reactionsP,N

Pain managementP,N

Education Patient and family education as it relates to discharge plan, diagnosis, activity, medications, diet,

smoking cessation, signs & symptoms requiring intervention .P, N, T-p, D, SW, T-r

Reinforce anticipated length of stay and discharge plan P

Smoking cessation advice/counseling if indicated**N,T-r, SW

Tests

Testing completed and reported** Cardiac likely: ECHO reported

Consider EP study, Stress testing , ILP

Neurally Mediated Tilt Testing, Carotid Massage

Consider CT/MRI/MRA if ordered by Neurology

Treatments Assess need for continued cardiac monitoring

IV /Tubes/Drains IV / IV access

Medications Consider conversion of IV meds to PO meds

Administration of pneumococcal/influenza(seasonal) vaccine if eligible**N

Evaluate for stool softener/laxative

Medications as indicated

Diet & Elimination Diet as ordered - Advance as toleratedP,N,D

Intake & Output if indicatedN

Monitor and document bowel and bladder eliminationN

Activity Ambulate as toleratedN,T-p

Promote independence with ADL's N

Discharge Planning /

Psychosocial

Reassess discharge planning needsN, CM,SW

Discharge notificationP,N,CM,SW

Consider discharge if appropriateP

Patient Outcomes Safety maintained

Ambulating/Performing ADL's w/optimal independence

Acceptable patient comfort level

Etiology determined

** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist

N = Registered nurse CM = Case Manager

Ph = Pharmacist SW = Social Worker

T-r = Respiratory Therapist T-p = Physical Therapist

Syncope Guideline

LIHN

Copyrighted 2010

Discharge Phase

Assessment &

Consultation

Reassessment of response to treatment and patient careP,N

Monitor effects of medication and assess for adverse drug reactionsP,N

Pain managementP,N

Education Assess patient and family understanding of discharge instructions including

diagnosis, activity, medications, pain management, diet, smoking cessation, signs & symptoms

requiring intervention, and follow up medical appointment**P,N,D,Ph,T-p,SW

(use teach back method)

Tests

Treatments D/C cardiac monitoring

IV /Tubes/Drains D/C IV access

Medications Medication reconciliation addressed**P,N

Diet & Elimination Diet as orderedP,N,D

Activity Ambulate as toleratedN,T-p

Discharge Planning /

Psychosocial

Discharge plan confirmed N,CM, SW

Patient Outcomes Hemodynamic stability

Stable and safe appropriate discharge

Patient/family demonstrates understanding of discharge instructions

Optimal independence

** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist

N = Registered nurse CM = Case Manager

Ph = Pharmacist SW = Social Worker

T-r = Respiratory Therapist T-p = Physical Therapist

LIHN

Copyrighted 2010

LIHN Guideline Test Recommendations

Syncope

References

Syncope Guideline

Comprehensive History* & Physical Exams**, Orthostatic BP, ECG, Labs

based on history

ECHO if history and physical exam or ECG does not provide a diagnosis or

underlying heart disease is suspected.

Ischemia evaluation may be appropriate for patients at risk with a history of

coronary artery disease.

Neurological evaluation should be pursued only if suggested by H&P

CT/ MRI/MRA if ordered by Neurology

Avoid Carotid Doppler & EEG***

Neurally mediated

or orthostatic likely

Nonsyncopal attack

Cardiac likely

Tilt Testing

Carotid Massage

ECHO

Cardiac Monitoring

Stress Testing

EP Study, Consider ILP

Confirm with specific tests

of specialist consultation

Neurally mediated tests

Syncope

Cardiac tests

LIHN

Copyrighted 2010

LIHN

Copyrighted 2010

LIHN

Copyrighted 2010

References

Syncope Guideline

1. Birgnole, M., Alboni, P., Benditt, D. et al. 2004. Guidelines on management (diagnosis and treatment)of

syncope- uptodate 2004. Europeand Heart Journal,(2004) 25, 2054 -2072

2. Brignole, M. Shen, W., 2009. syncope management from emergency department to hospital. Journal of

American College of Cardiology, 2008;51;284-287 doi:10.1016/jacc.2007.07.092 Retrieved from

http://content.onlinejacc.org/cgi/content/full/51/3/284

3. Brignole, M., Ulngar, A., Bartoletti, A., et al. 2006. Standardized-care pathway vs. usual management of

syncope patients presenting as emergencies at general hospitals, The European Society of Cardiolgy

2006 Vol 8 644-650

4. Chen, L., Benditt, D., Shen, W., 2008. Management of syncope in adults: An update. Mayo clinic, 2008

Retrieved March 6, 2009 from. http://ww.mayclinciproceeding.com/content/83/11/1280.full

5. Jhanjee, R., Van Dijk, J., Sakaguchi, S. et al. 2006. Syncope in adults: Terminology, classification, and

diagnostic strategy, Pacing Clincal Eletrophysiology, 2006;29(2):1160-1169

6. Strickberger, S., Benson, d., Biaggioni, I. et al. 2006. AHA/ACCF scientific statement on the evaluation of

syncope. Circulation, American Heart Association, 2006 ISSN:0009-7322

This Clinical Guideline has been developed with support from your institution as a member of Long Island

Health Network. It is strongly recommended for the treatment of patients with this diagnosis. It does not take

into account unusual patient needs which may dictate different plans of care.