The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group

Abstract

The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge.

Fig. 1

Modified Delphi process (a) and eEPC legend (b, c). The here applied modified Delphi process is visualized in (a), starting in the center with the core syncope expert group creating a first draft which is that transferred to the whole EUSEM syncope group for revision and finally is received back by the core syncope expert group after feedback. Written feedback and consensus were reached in a face-to-face meeting of the EUSEM syncope group on the basis of which, Fig. 2 (eEPC) was created. In (b and c) two scenarios are shown on how eEPCs can be built and understood (together with a legend). eEPC, extended event process chain.

Fig. 2

Detailed eEPC of the core syncope management process in the ED context. (a) Part 1 (field 1–21): Arrival and triage. (b) Part 2 (field 22–47): Diagnostic procedures. (c) Part 3 (field 48–61): Risk stratification. The presented eEPC shows the detailed process chain of syncope patients presenting in the ED. It is, for visualization and explanatory reasons, separated into three parts here, starting with (a) (triage and arrival), continuing with (b) (diagnostic procedures) and ending with (c) (risk stratification). The color codes can be understood as shown in the legend of Fig. 1b and c. ED, emergency department; eEPC, extended event process chain; SOP, standard operation procedures.

Fig. 3

Explanatory flowchart algorithm, on the basis of the syncope eEPC, for practical use in the ED context. This flowchart shows an example of how the syncope ED eEPC (Fig. 2) can be transferred into an algorithm for practical use in the ED. *some EDs bypass triage if patient arrives via EMS; **add after medical examination if not done before or if parameters are missing. ED, emergency department; EMS, emergency medical service; Lab, laboratory; TLOC, transient loss of consciousness.