ED crowding limits the ability of the emergency providers to provide quality care, is a
growing crisis in North America and Europe, and leads to unsafe and rushed disposition
decisions which compromise patient care. On the other hand, hospital admission is
expensive, and an increasing awareness of nosocomial morbidity and the harms of
unnecessary testing and hospitalization exert countervailing pressure on low-yield
admissions from the ED. Therefore, improved accuracy in ED disposition decision-making is
more important than ever, and syncope typifies a common, high stakes condition in which
improvements in efficiency are badly needed.
Identifying which patients will benefit from further cardiac rhythm monitoring and/or
hospital admission is essential to reduce both adverse outcomes and high costs. A
comprehensive literature review of risk-tools and international guidelines concede that
previously published tools lack or have failed external validation, are excessively
complex, include as outcomes obvious conditions readily identified during the index ED
evaluation, or lacked power and specificity. These tools also do not offer specific
clinical actions and are not supported by the guidelines. The CSRS addresses each of the
above weaknesses and coupled with outpatient live cardiac monitoring is an innovative and
standardized approach to ED syncope management to expedite ED care, improve patient
safety and reduce healthcare costs. The investigators have identified the barriers and
facilitators to effectively adapt knowledge into local contexts as per the Knowledge to
Action cycle, and have selected implementation strategies accordingly. The proposed pilot
study is a right step before widescale implementation.
The primary objective of this pilot study is to assess the feasibility of implementing
the practice recommendations. The secondary objectives are to assess the effectiveness
and safety of the intervention, implementation of the CSRS-based practice
recommendations. Specific objectives include:
Feasibility objectives:
Primary: to assess the reach of the intervention Secondary: to assess the adoption,
adherence, and sustainability of the intervention; to assess the acceptability, the
feasibility of use and the complexity of the intervention; and to assess the satisfaction
to the dose (i.e., exposure) of the intervention received including support and
resources.
Effectiveness objectives:
Primary: to assess the impact on ED disposition time, defined as the time interval
between ED physician initial assessment and ED disposition.
Secondary: to assess the impact on hospitalizations, investigations and consultations
performed in the ED.
Safety objective: To assess mortality, return ED visits and hospitalization within
30-days and 1-year of the index ED visit (generic patient safety outcome) and to monitor
the safety of the CSRS application by assessing the 30-day serious outcomes after ED
disposition (syncope specific short-term serious outcome).
We will conduct the study over a 9-month period, with the TOH and QCH EDs receiving the
intervention at the 3rd and 4th month respectively. The first month of the intervention
period will be designated as a transition period during which we will undertake intense
educational efforts. The total intervention period for the QCH and TOH EDs will be 5 and
6 months respectively.
