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Showcasing Best Practice In Syncope
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Streaming the syncope care pathway through a multidisciplinary blackout service
Jayne Mudd, Professor Nick Linker & Dr Andrew Turley
The South Tees Blackout Service, UK
The South Tees Blackout Service was established in 2010 and provides rapid, standardised clinical assessment and management for patients experiencing Transient Loss of Consciousness (TLoC).
The service is delivered across two sites by nurses specialising in cardiac rhythm management and epilepsy with same day access to a consultant neurophysiologist and cardiologists. Close liaison with the emergency department (ED), falls team, elderly care and psychogenic services are integral. Referrals are both triaged and seen by specialist nurses within two weeks of referral.
The service off ers a nurse-led implant and explant service for implantable loop recorders (ILR) including follow up via remote monitoring systems. Referral sources include ED, general practice and in-patient specialities. Monthly multidisciplinary team meetings allow for complex case review whilst providing a platform for education.
62 year old gentleman with a history of diabetes, ischaemic heart disease and asthma presents to emergency department with sudden, no warning blackout. Two episodes in three months with significant facial injury sustained. Referral made to blackout service and patient discharged.
Nine days later: Blackout clinic, clinical assessment by the nurses, witness account o btained. Examination: unremarkable, Active stand: no signifi cant postural drop in BP, ECG, 72 hour holter – no arrhythmias identified. Transthoracic echocardiogram: mildly impaired LV function.
Discussed with cardiologist and recommendation for ILR made. ILR implanted by nurses seven days from initial assessment in blackout clinic. Patient monitored via remote monitoring service - checked daily by the nursing team.
9 days later: Automated event via remote monitor demonstrates a 12 second ventricular pause. Patient contacted immediately by the nurses and confirms another sudden no warning blackout that correlates with the automated event. Discussed with cardiologist on the same day and listed for permanent pacemaker implant.
25 days later: Permanent pacemaker implant performed. On-going care provided through the pacing clinic.
Audit pre and post service demonstrates signifi cant reductions in a number of outcomes: wait for first assessment, diagnosis and treatment times. Hospital admissions for TLoC were reduced from 64 to 23 per month. Diagnostic yield increased from 10% to 17% following introduction of the nurse-led ILR service.
72% of patients receive diagnosis at first appointment. 99% of patients reported high levels of satisfaction.
The multi-disciplinary service allows for prompt access to appropriate specialists enabling provision of high quality care through a standardised approach to investigation and management. Investigations are appropriate and kept to a minimum.