Syncope. Quality Measures Length of Stay RCC Costs per Case. Critical Events. Evaluation Phase

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Curtis Merritt
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1 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

2 Syncope Guideline Assessment & Consultation Complete Day 1 Comprehensive history and physical** P Baseline skin assessment and documentation of present on admission P,N Baseline pain assessment** N VTE(DVT) risk assessment ** P,N VS including orthostatic blood pressures** N Physician Cardiac and Neurological Screening if indicated P Education Complete Day 1 Assess barriers to learning P,N Orientation to environment, safety protocols N Infection control procedures/ protocols P,N Medication teaching as appropriate N Evaluation / Acute Phase Admission assessment including smoking history N Initiate plan of care P,N Fall / Risk assessment P,N MRSA/VRE screen if indicated N Documentation of screening for pneumococcal / influenza (seasonal) vaccine** N Explain all tests, procedures, plan of care and expected length of stay P,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 IV /Tubes/Drains Cardiac Likely- Cardiac Monitoring IV / IV access Medications Complete Day 1 Medication Reconciliation addressed** P,N Appropriate VTE(DVT) prophylaxis if applicable** Medications as indicated Diet & Elimination Activity Discharge Planning / Pyschosocial Patient Outcomes Diet As Ordered - Advance As Tolerated P,N,D Intake & Output if indicated N Monitor and document bowel and bladder elimination N N, T-p Ambulate as tolerated Assess support network N,CM,SW Initiate discharge plan including appropriate referrals N,CM,SW 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

3 Syncope Guideline Assessment & Consultation Progressive Phase Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N Education Tests Treatments IV /Tubes/Drains Medications Diet & Elimination Activity Discharge Planning / Psychosocial Patient and family education as it relates to discharge plan, diagnosis, activity, medications, diet, P, N, T-p, D, SW, T-r smoking cessation, signs & symptoms requiring intervention. Reinforce anticipated length of stay and discharge plan P N,T-r, SW Smoking cessation advice/counseling if indicated** 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 Assess need for continued cardiac monitoring IV / IV access 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 as ordered - Advance as tolerated P,N,D Intake & Output if indicated N Monitor and document bowel and bladder elimination N Ambulate as tolerated N,T-p Promote independence with ADL's N N, CM,SW Reassess discharge planning needs Discharge notification P,N,CM,SW Consider discharge if appropriate P 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

4 Syncope Guideline Assessment & Consultation Education Discharge Phase Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N 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 Activity Diet as ordered P,N,D Ambulate as tolerated N,T-p N,CM, SW Discharge Planning / Discharge plan confirmed Psychosocial 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

5 Guideline Test Recommendations Syncope 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 Syncope References Nonsyncopal attack Cardiac likely Syncope Guideline Neurally mediated or orthostatic likely Confirm with specific tests of specialist consultation Cardiac tests Neurally mediated tests ECHO Cardiac Monitoring Stress Testing EP Study, Consider ILP Tilt Testing Carotid Massage CT/ MRI/MRA if ordered by Neurology Avoid Carotid Doppler & EEG***

8 References Syncope Guideline 1. Birgnole, M., Alboni, P., Benditt, D. et al Guidelines on management (diagnosis and treatment)of syncope- uptodate Europeand Heart Journal,(2004) 25, Brignole, M. Shen, W., syncope management from emergency department to hospital. Journal of American College of Cardiology, 2008;51; doi: /jacc Retrieved from 3. Brignole, M., Ulngar, A., Bartoletti, A., et al Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals, The European Society of Cardiolgy 2006 Vol Chen, L., Benditt, D., Shen, W., Management of syncope in adults: An update. Mayo clinic, 2008 Retrieved March 6, 2009 from Jhanjee, R., Van Dijk, J., Sakaguchi, S. et al Syncope in adults: Terminology, classification, and diagnostic strategy, Pacing Clincal Eletrophysiology, 2006;29(2): Strickberger, S., Benson, d., Biaggioni, I. et al AHA/ACCF scientific statement on the evaluation of syncope. Circulation, American Heart Association, 2006 ISSN: 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.

Acute Coronary Syndrome

Acute Coronary Syndrome Quality Measures Length of Stay RCC Costs per Case Critical Event(s) Evaluation /Acute Phase ECG ASA on arrival (unless documented contraindication) Troponin STAT, repeat once in