Factors facilitating and hindering the implementation of the European Society of Cardiology Syncope Guidelines at the Emergency Department: A nationwide qualitative study

Abstract

Aims: Syncope care is often fragmented and inefficient. Structuring syncope care through implementation of guidelines and Syncope Units has been shown to improve diagnostic yield, reduce costs and improve quality of life. We implemented the European Society of Cardiology (ESC) 2018 syncope guidelines at the Emergency Departments (ED) and established Syncope Units in five Dutch hospitals. We evaluated the implementation process by identifying factors that hinder ('barriers') and facilitate ('facilitators') the implementation. Methods and results: We conducted, recorded and transcribed semi-structured interviews with 19 specialists and residents involved in syncope care from neurology, cardiology, internal medicine and emergency medicine. Two researchers independently classified the reported barriers and facilitators, according to the framework of qualitative research (Flottorp), which distinguished several separate fields ('levels'). Software package Atlas.ti was used for analysis. We identified 31 barriers and 22 facilitators. Most barriers occurred on the level of the individual health care professional (e.g. inexperienced residents having to work with the guideline at the ED) and the organizational context (e.g. specialists not relinquishing preceding procedures). Participants reported most facilitators at the level of innovation (e.g. structured work-flow at the ED). The multidisciplinary Syncope Unit was welcomed as useful solution to a perceived need in clinical practice. Conclusion: Implementing ESC syncope guidelines at the ED and establishing Syncope Units facilitated a structured multidisciplinary work-up for syncope patients. Most identified barriers related to the individual health care professional and the organizational context. Future implementation of the multidisciplinary guideline should be tailored to address these barriers.

A cross-sectional nationwide survey of guideline based syncope units in the Netherlands: the SU-19 score—a novel validation for best practices

“…Implementation of guidelines remains challenging in the emergency department. 8 Our national survey shows that implementation of guidelines based syncope care in the SUs appears to be much better than expected.…”

“… 1 , 9 , 40–44 We realize that high costs hamper the use of CBP for CSM and AST measurement. 8 Regarding the protocol used for CSM, there is variation in the position of the patients during CSM and simple adjustments in the protocol results in best practice. 42 …”

“…Therefore, we obtained a list of all (general and university) hospitals in the Netherlands from the national institute for public health. 8 We then contacted all neurology, internal medicine, and cardiology outpatient clinics in all Dutch hospitals by phone and obtained information regarding specialized care for syncope patients. 23 Hospitals with multiple locations were regarded as one hospital.…”

“…Most barriers appeared on the level of healthcare professionals and organizational context. 8 Specialized syncope units (SUs) may be of help in providing the standardized assessment of syncope patients. 5 A standardized approach to patients experiencing syncope is crucial as starting point on which treatment is based; however, how to handle the syncope patient is equally, if not more, important in order to prevent syncope recurrence.…”

Syncope Diagnosis at Referral to a Tertiary Syncope Unit: An in-Depth Analysis of the FAST II

“…The ESC guideline on syncope underscores the importance of this aspect of history-taking in the practical instructions [ 17 ]. A recent study showed that there are several barriers that impact the implementation of syncope guidelines in the emergency department [ 18 ]. The main barriers are at the healthcare professional level, reflecting the inadequate time physicians give to taking a thorough history and performing orthostatic blood pressure measurements, combined with insufficient experience/knowledge.…”