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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.