title: Syncope Best Practices: A Syncope Clinical Practice Guideline to Improve Quality.
abstract: OBJECTIVE
  To determine whether implementation of a standardized clinical practice guideline (CPG) for the evaluation of syncope would decrease practice variability and resource utilization.
  
  
  METHODS
  A retrospective review of medical records of patients presenting to our practice for outpatient evaluation of syncope before and after implementation of the CPG. The guideline included elements of history, physical exam, electrocardiogram, and "red flags" for further testing.
  
  
  METHODS
  Outpatient pediatric cardiology offices of a large pediatric cardiology practice.
  
  
  METHODS
  All new patients between 3 and 21 years old, who presented to cardiology clinic with a chief complaint of syncope.
  
  
  METHODS
  The CPG for the evaluation of pediatric syncope was presented to the providers.
  
  
  METHODS
  Resource utilization was determined by the tests ordered by individual physicians before and after initiation of the CPG. Patient final diagnoses were recorded and the medical records were subsequently reviewed to determine if any patients, who presented again to the system, were ultimately diagnosed with cardiac disease.
  
  
  RESULTS
  Of the 1496 patients with an initial visit for syncope, there was no significant difference in the diagnosis of cardiac disease before or after initiation of the CPG: (0.6% vs. 0.4%, P = .55). Electrocardiography provides the highest yield in the evaluation of pediatric syncope. Despite high compliance (86.9%), there were no overall changes in costs ($346.31 vs. $348.53, P = .85) or in resource utilization. There was, however, a decrease in the variability of ordering of echocardiograms among physicians, particularly among those at the extremes of utilization.
  
  
  CONCLUSIONS
  Although the CPG did not decrease already low costs, it did decrease the wide variability in echo utilization. Evaluation beyond detailed history, physical exam, and electrocardiography provides no additional benefit in the evaluations of pediatric patients presenting with syncope.
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Phelps
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Ritu
authors.initials: R
authors.lastname: Sachdeva
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: William T
authors.initials: WT
authors.lastname: Mahle
authors.affiliation: Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Courtney E
authors.initials: CE
authors.lastname: McCracken
authors.affiliation: Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Kelleman
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: McConnell
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Fischbach
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Cardis
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Campbell
authors.affiliation: Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga.|Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Oster
mesh_terms: D000293:Adolescent; D002309:Cardiology / Q000191:economics / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography / Q000191:economics / Q000592:standards*; D004562:Electrocardiography / Q000191:economics / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000191:economics / Q000592:standards*; D017048:Health Care Costs / Q000592:standards; D006295:Health Resources / Q000592:standards / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000592:standards; D006801:Humans; D008297:Male; D008499:Medical Records; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards; D011237:Predictive Value of Tests; D017064:Process Assessment, Health Care / Q000191:economics / Q000592:standards*; D015397:Program Evaluation; D058996:Quality Improvement / Q000191:economics / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000191:economics / Q000592:standards*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires / Q000592:standards; D013575:Syncope / Q000175:diagnosis* / Q000191:economics / Q000209:etiology / Q000628:therapy; D016896:Treatment Outcome; D055815:Young Adult
keywords: Best Practices; Practice Guidelines; Quality Improvement; Syncope