title: Implementing a guideline to improve management of syncope in the emergency department.
abstract: OBJECTIVE
  Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope.
  
  
  METHODS
  Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care.
  
  
  RESULTS
  A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing after our quality improvement intervention: complete blood count testing decreased from 36% (95% confidence interval 29% to 43%) to 16% (12% to 22%) and electrolyte testing from 29% (23% to 36%) to 12% (8% to 17%). Performance of recommended testing increased, such as electrocardiograms and pregnancy testing in postpubertal girls. Despite a reduction in diagnostic testing among children with syncope, patients were not more likely to undergo subsequent diagnostic testing or seek further medical care following their ED visit.
  
  
  CONCLUSIONS
  Implementation of a quality improvement intervention for the ED evaluation of pediatric syncope was associated with reduced low-yield diagnostic testing, and was not associated with subsequent testing or medical care.
authors.affiliation: Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
authors.forename: Sabrina E
authors.initials: SE
authors.lastname: Guse
authors.affiliation: Departments of Medicine, and.
authors.forename: Mark I
authors.initials: MI
authors.lastname: Neuman
authors.affiliation: Department of Emergency Medicine, George Washington University, Washington, District of Columbia.
authors.forename: Megan
authors.initials: M
authors.lastname: O'Brien
authors.affiliation: Cardiology, Boston Children's Hospital, Boston, Massachusetts; and.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Alexander
authors.affiliation: Departments of Medicine, and.
authors.forename: Mark
authors.initials: M
authors.lastname: Berry
authors.affiliation: Departments of Medicine, and.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Monuteaux
authors.affiliation: Departments of Medicine, and andrew.fine@childrens.harvard.edu.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Fine
mesh_terms: D000293:Adolescent; D002648:Child; D019468:Disease Management; D004636:Emergency Service, Hospital / Q000592:standards* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies; D013575:Syncope / Q000175:diagnosis* / Q000628:therapy*; D055815:Young Adult
keywords: children; guideline; syncope