Does the use of a syncope diagnostic protocol improve the investigation and management of syncope?

Objectives: To assess the efficacy of a protocol designed to improve the diagnosis and management of syncope. Design: Prospective outcome analysis of all patients presenting with syncope for the 12 month period from 1 November 2000 to 31 October 2001, compared with a retrospective study of all patients presenting with syncope during the calendar year 1998. Use of the protocol commenced in September 2000. Setting: Eastbourne District General Hospital, serving a population of approximately 250 000; 25% are older than 65 years. Subjects: 421 consecutive patients presenting with syncope, investigated prospectively in January 2000 and compared with 660 patients retrospectively analysed for the calendar year 1998. Results: In 1998, 71% of patients with syncope received a diagnostic classification. In January 2000 there was an appropriate diagnostic hypothesis for every patient. Ultimately a diagnosis was made for 78% of patients according to accepted criteria ( p = 0.003). Use of tests with the highest diagnostic effectiveness, such as tilt tests, increased in 2001 and many tests were used more appropriately ( such as echocardiography). However, non-diagnostic tests were still frequently used ( such as chest radiography, electroencephalography, and carotid Doppler studies). Costs of investigation and hospital stay rose from pound611 to pound1384 (E874 to E1980) per patient (p< 0.001), with cost per diagnosis increasing from £870 (E1245) in 1998 to £1949 (E2790) (p< 0.001). Conclusion: The syncope protocol improved diagnosis and the use of appropriate investigations. However, significant inappropriate investigation and hospital admission still occurred. The protocol allowed reliable triage of syncopal patients into high and low risk groups.