HNY Policy and Pathway Repository - York

York and Scarborough Teaching Hospital NHS trust are pleased to launch the new Syncope Clinic Service pathway which is now open for referrals. More details can be found below regarding the actual service, patients eligible for referral and the pathways to refer the patient in.
 

Syncope clinic

Syncope is defined as a total loss of consciousness (TLOC) due to global cerebral hypo perfusion characterised by rapid onset, short duration, and spontaneous complete recovery.

Syncope can be divided into three areas of possible aetiology: reflex syncope; orthostatic syncope; and cardiac syncope. Vasovagal syncope, which is a branch of reflex syncope, is thought to be the most common cause, followed by cardiac syncope. While reflex syncope is usually due to a benign cause, cardiac syncope carries a much higher mortality risk which is further increased by factors such as older age, the presence of heart failure and other co-morbidities. Currently there is no streamlined approach for a patient that presents with syncope in York and Scarborough Trust, whether this is to a GP or in ED. Therefore it is the responsibility of the attending clinician to decide which service or investigation they feel the patient requires. This approach lacks standardisation and can result in patients with the same presenting complaint being referred to different services. This isn’t just the case in at York and Scarborough Trust, evaluation and treatment of syncope can often be haphazard and un-stratified.

After shadowing a well-established syncope clinic at James Cook Hospital, I started the process to develop one here at York Hospital. The patients will be referred either via ED or their GP following the relevant referral pathway. The referral will then be triaged and the patient booked into a specific syncope clinic run by a Cardiac Clinical Scientist under the supervision of Cardiology Consultants.

If the referral is deemed to be urgent the target will be to see these patients within 2 weeks, the routine referrals within 6 weeks. I encourage you to aid in the referral process by providing all the necessary information as detailed below. It will be extremely helpful where possible to give the patient a witness recollection form. This should be filled out by anyone who witnessed their episode of syncope and aids greatly in obtaining a history when they attend clinic. This link for this can be found below.

This will offer a standardised approach in line with the service offered at James Cook. After taking an in-depth history from the patient and any witness statements, either a diagnosis will be made and advice given. Or further investigations and follow up will be arranged. This will lead to a quicker diagnosis and more specific management for this patient group.

Please see below for specific referral information.

It is important to identify any of the following Red Flag features and indicate these on the referral form. These patients require urgent assessment (within 2 weeks) and may need consultant follow up

• Family history of sudden cardiac death <40 years old
• Syncope during exercise
• New onset chest discomfort, breathlessness, abdominal pain or headache
• Sudden onset palpitations immediately followed by syncope
• Undiagnosed systolic murmur, i.e. a newly detected murmur
• Previously diagnosed with structural heart disease or coronary artery disease
• Persistent bradycardia <40bpm on 12 lead ECG
• Cardiac device implanted
   

Neurological red flags - should be referred to specialist in Epilepsy within 2 weeks

• A bitten tongue
• Head turning to one side during TLOC
• No memory of abnormal behaviour that was witnessed before or after TLOC by someone else
• Unusual posturing
• Prolonged limb jerking (note that brief seizure-like activity can often occur during uncomplicated faints).
• Prodromal aura

Management

• Urgent patients should be seen within two weeks.
• Non-urgent patients will be seen within six weeks.
• In around half of patients a diagnosis can be made from the history provided by the patient and/or any witnesses without the need for investigations.
• Where a neurological cause is suspected the clinicians will liaise with neurology colleagues directly without referring back to GPs.
• Of those who do have investigations the following are most commonly used:
  • Up to two week heart rhythm monitoring with a wearable device
  • Tilt table tests
  • Exercise testing
  • Implantable heart rhythm monitoring (for up to three years)
  • Echocardiogram if murmur heard or anatomical abnormality suspected
• Patients will be told their results in the most efficient and appropriate way for them, e.g. by letter, phone consultation or face to face.
• On discharge from the clinic many patients will be given an option of Patient Initiated Follow Up (PIFU) for a period of time in case there is any recurrence or other concern. PIFU enables patients to get back in touch with the hospital without going via their GP.

Witness recollection form and ‘Advice following an episode of syncope’ leaflet can be accessed here:

York and Scarborough Teaching Hospitals NHS Foundation Trust - Syncope Clinic (York) (yorkhospitals.nhs.uk)

Any questions please don’t hesitate to get in touch, chloe.howard9@nhs.net 

Indications for referral

• Episode of total loss of consciousness
   

Information to include in referral letter

• How many episodes, date and time of most recent
• 12 lead ECG
• Heart sounds – If a undiagnosed murmur is detected mark the referral urgent
• Supine and standing BP
• Blood tests are not required routinely, only if another reason for suspecting abnormality
• Current medication
• History of alcohol, tobacco consumption and illicit drugs (Particularly use of either prior to the collapse)
• Witness Description Form – contemporaneously recorded history will aid speed and accuracy of diagnosis (see below for link to form)

Please encourage patients and witnesses to provide these to you to be sent with the referral where possible, but don’t delay an urgent referral waiting for these.

 

How to refer

Referrals to the Syncope can be submitted via Gateway to the RSS using the following speciality and Clinic type. Please note you will be prompted to complete a brief questionnaire to ensure suitability of the referral.

Speciality - Diagnostic Physiological Measurement

Clinic type - Cardiac Physiology- BP Monitoring

Eye witness form for an episode of syncope

 

Syncope Service (York) - York & Scarborough Teaching Hospital NHSFT

7985333 – York Hospital

Specialty	Diagnostic Physiological Measurement
Clinic Type	Cardiac Physiology – BP Monitoring
Service Name	Syncope clinic (York) York & Scarborough Teaching Hospitals NHSFT-RCB
Booking Guidance	Age: 16yrs and over Conditions Treated: Syncope – total loss of consciousness. Procedures Performed: 24/48/72/1 week/2 week ECG monitoring Implantable loop recorder Echocardiogram Exclusions: People already under cardiology follow up at Scarborough or York Hospital People with new onset exertional chest pain should be referred through chest pain protocol People with AF should be managed through the published AF pathway People with new Heart Failure should be managed through the published Heart Failure pathway People under 16yrs (if under 16 please refer to paediatric services) Suggested Investigations: