Background: Syncope is characterized by a transient loss of consciousness, with vasovagal syncope being the most common cause. According to the American College of Cardiology (1), routine cardiac imaging, including transthoracic echocardiography (TTE), is not recommended in the evaluation of syncope unless there is a clinical suspicion of a cardiac cause, based on the patient’s history, physical examination, or ECG findings. In our study, we found a significant number of inappropriate TTEs being ordered for patients with the indication syncope, despite histories and physical exams that did not suggest a cardiac origin. Unnecessary exams lead to higher healthcare costs and hospitalization days. Our quality improvement project aimed to decrease unnecessary TTEs by 30% from July 9 2023 to June 30 2024 in order to improve resource utilization.
Methods: We performed a retrospective analysis of patients admitted with syncope who had TTEs completed between January 1 2023, and July 9 2023. Pre-intervention, there were 2.42 TTE completed orders per 1,000 patient-care days (PCD). Through a chart review of a three-month sample of completed TTEs with the indication “syncope,” we found that the monthly average of inappropriate TTEs ordered was approximately 88.5%. Inappropriate orders included absence of new murmurs, signs/symptoms of heart failure, or significant cardiac history. The first PDSA cycle in July 2023 was providing education at the hospitalists’ monthly meeting and residents’ noon conference lecture. Upon further chart review, we found a higher rate of inappropriate TTE orders being placed during night shifts and in the observation unit. To address this, our second PDSA cycle implemented an educational intervention for residents and interns working night shifts, as well as nurse practitioners working in the observation unit. Educational posters were also displayed in key areas to further promote the guidelines.
Results: Pre-intervention data revealed 2.42 TTE orders per 1,000 PCD. During the following 12 months of review, the number of unnecessary TTE orders steadily decreased. By June 2024 the rate of TTE orders dropped to 1.37 per 1,000 PCD, which was an overall 43.4% reduction. Additionally, the average length of stay for syncope encounters decreased from 5.02 to 4.16 days.
Conclusions: Our study found that there was a high percentage of inappropriate TTE obtained for syncope work up, which leads to higher costs to patients and the healthcare system. Our syncope quality improvement initiative was successful in meeting its goal for reduction of inappropriate TTEs obtained. It has also led to a decrease in length of stay for syncope encounters, though it is still higher than the nationwide average LOS for syncope hospitalizations. This could be partially attributed to TTE orders causing delays in other aspects of care, ie physical therapy evaluations and other evaluations. Moving forward, in addition to further decreasing inappropriate TTEs, our remaining goal is to maintain a sustainable reduction in unnecessary testing. It is particularly crucial to improve resource utilization in a community hospital where resources are limited.