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Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial

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Abstract

Background

We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation.

Methods

A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2–3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058.

Results

1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period.

Conclusion

In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation.

Résumé

Contexte

Nous avons mis au point la Canadian Syncope Pathway (CSP) basée sur le Canadian Syncope Risk Score (CSRS) pour aider les services d’urgence à gérer la syncope. Cette étude pilote de mise en œuvre a évalué l’inclusion des patients, la durée de la période de transition, ainsi que les mesures de processus (engagement, portée, adoption et fidélité) pour se préparer à la mise en œuvre multicentrique

Méthodes

Un essai par étapes non randomisé dans deux hôpitaux a été mené sur une période de 7 mois. Après 2 à 3 mois dans l’état de contrôle, les hôpitaux sont passés progressivement à l’état d’intervention. Les participants à l’étude étaient des médecins du service de l’urgence et non du service de l’urgence, ou leurs délégués, et des patients (âgés de 18 ans) atteints de syncope. Nous avons cherché à analyser les caractéristiques des patients, la prise en charge des urgences, y compris la décision de disposition, et l’application des recommandations du CSRS pour tous les patients admissibles pendant la période d’intervention. Nos cibles étaient le taux d’inclusion de 95 %, l’adoption de 70 % (proportion de médecins qui ont appliqué la voie), la portée de 60 % (intervention appliquée aux patients admissibles) et la fidélité de 70 % (application des recommandations appropriées) pour tous les patients admissibles. Enregistrement des essais cliniques NCT04790058.

Résultats

1002 patients éligibles (âge moyen 56,6 ans; 51,0% d’hommes) ont été inclus : 349 patients pendant le contrôle et 653 patients pendant la période d’intervention. La participation des médecins variait de 39,7 % à 97,1 % pour la présentation aux réunions. Les mesures du processus pour le premier mois et la fin de l’intervention étaient les suivantes : adoption 70,7 % (58/82) et 84,4 % (103/122), atteinte de 67,5 % (108/160) et 55,0 % (359/653), fidélité chez les patients ayant rempli le formulaire de données médicales 86,3 % (88/102) et 88,3 % (294/333), versus fidélité chez tous les patients admissibles 83,8 % (134/160) et 83,3 % (544/653) respectivement, sans différence significative de fidélité à un mois et à la fin de la période d’intervention.

Conclusion

Dans cette étude pilote, nous avons atteint tous les points de repère prédéterminés pour procéder à la mise en œuvre du PSC multicentrique, sauf la portée. Nos résultats indiquent qu’une période de transition d’un mois sera adéquate, bien que des rappels réguliers seront nécessaires pendant la mise en œuvre à grande échelle.

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Acknowledgements

We are deeply indebted to all the patients who participated in this study and gratefully acknowledge the emergency physicians at the study sites who recruited the patients and the emergency medicine residents who helped in this process. We acknowledge the following members of our research team: Jane Jungyoon Park, Komal Valliani, Anton Saarimaki and Dong Vo from The Ottawa Methods Centre. We would also like to thank Dr. Phong Hong Vu, PhD for his help with statistical analysis. Dr. Thiruganasambandamoorthy is supported through a Physicians’ Services Incorporated Foundation Mid-Career Clinical Researcher award and University of Ottawa Tier-1 Clinical Research Chair award. Drs. Eagles and Yadav are supported by the University of Ottawa Junior Clinical Research Chair awards. The funders take no responsibility for the design, conduct, results, or interpretations presented here.

Funding

The study was funded by the Cardiac Arrhythmia Network of Canada (IMPL-002) as part of the Networks of Centres of Excellence (NCE) and TOHAMO.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    Venkatesh Thiruganasambandamoorthy, Warren J. Cheung, Krishan Yadav & Debra Eagles

  2. The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada

    Venkatesh Thiruganasambandamoorthy, Phuong Anh Iris Nguyen, Preeti Gupta, Bahareh Ghaedi, George Z. Q. Cao, Warren J. Cheung, Marie-Joe Nemnom, Krishan Yadav, Debra Eagles, Jamie Brehaut & Monica Taljaard

  3. School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Venkatesh Thiruganasambandamoorthy, Krishan Yadav, Debra Eagles & Monica Taljaard

  4. Emergency Department, Queensway-Carleton Hospital, Ottawa, ON, Canada

    Maria Keller & Bikalpa Khatiwada

  5. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

    George Z. Q. Cao

  6. Canadian Cardiac Care, Windsor, ON, Canada

    Wadea Tarhuni

  7. Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada

    Wadea Tarhuni

  8. Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, ON, Canada

    Genevieve Rouleau

  9. Université du Québec en Outaouais, St-Jérôme, QB, Canada

    Genevieve Rouleau

  10. Institute for Better Health & Learning Health System Program Lead, Trillium Health Partners, Toronto, ON, Canada

    Laura Desveaux

  11. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Laura Desveaux

Authors
  1. Venkatesh Thiruganasambandamoorthy
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  2. Maria Keller
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  10. Krishan Yadav
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  11. Debra Eagles
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  12. Jamie Brehaut
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  13. Wadea Tarhuni
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  14. Genevieve Rouleau
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  15. Laura Desveaux
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  16. Monica Taljaard
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Corresponding author

Correspondence to Venkatesh Thiruganasambandamoorthy.

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The authors declare that they have no competing interests.

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Additional information

Communicated by Eddy Lang.

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Thiruganasambandamoorthy, V., Keller, M., Nguyen, P.A.I. et al. Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial. Can J Emerg Med 25, 808–817 (2023). https://doi.org/10.1007/s43678-023-00570-7

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