Regional Implementation of a Pediatric Cardiology Syncope Algorithm Using Standardized Clinical Assessment and Management Plans (SCAMPS) Methodology

Abstract

BackgroundPediatric syncope is common. Cardiac causes are rarely found. We describe and assess a pragmatic approach to these patients first seen by a pediatric cardiologist in the New England region, using Standardized Clinical Assessment and Management Plans (SCAMPs).Methods and ResultsAmbulatory patients aged 7 to 21 years initially seen for syncope at participating New England Congenital Cardiology Association practices over a 2.5‐year period were evaluated using a SCAMP. Findings were iteratively analyzed and the care pathway was revised. The vast majority (85%) of the 1254 patients had typical syncope. A minority had exercise‐related or more problematic symptoms. Guideline‐defined testing identified one patient with cardiac syncope. Syncope Severity Scores correlated well between physician and patient perceived symptoms. Orthostatic vital signs were of limited use. Largely incidental findings were seen in 10% of ECGs and 11% of echocardiograms. The 10% returning for follow‐up, by design, reported more significant symptoms, but did not have newly recognized cardiac disease. Iterative analysis helped refine the approach.Conclusions SCAMP methodology confirmed that the vast majority of children referred to the outpatient pediatric cardiology setting had typical low‐severity neurally mediated syncope that could be effectively evaluated in a single visit using minimal resources. A simple scoring system can help triage patients into treatment categories. Prespecified criteria permitted the effective diagnosis of the single patient with a clear cardiac etiology. Patients with higher syncope scores still have a very low risk of cardiac disease, but may warrant attention.

Long-term Effects of an Evidence-based Guideline for Emergency Management of Pediatric Syncope

“…Coincident with this EBG, the Department of Cardiology at Boston Children’s Hospital also examined their ambulatory practices in the evaluation of syncope. 20 The division chief’s annual evaluation of physician performance, including rotating metrics of adherence to a single guideline as a marker of evidence-based practices, likely promotes adherence to the guidelines. Lastly, escalating national discussion on cost containment in healthcare may have impacted clinical practices.…”

Impact of standardized clinical assessment and management plans on resource utilization and costs in children after the arterial switch operation

“…An important limitation of the current study is the use of a single center design, limiting the generalizability of the results to other institutions and patient populations. Although we have shown that SCAMPs can be deployed across multiple institutions in a network, each center will need to validate the impact of a SCAMP on their practice. The costs required to create, execute, and analyze the ASO SCAMP were not measured.…”

Reducing Cost Through Standardization

“…1 and Table 1). Regional implementation of pediatric SCAMPs for evaluation of chest pain and syncope in children and adolescents has been successful and well-received by both providers and patients [38,39]. The first hurdle facing any care pathway is achieving physician buy-in, which can be partially assessed by measuring adherence and resultant practice variation.…”

“…Resource utilization also significantly decreased for a number of diagnostic testing modalities commonly used in the evaluation of chest pain. In the pre-SCAMP cohort, nearly 30 % of patients underwent exercise stress testing, despite a lack of established clinical utility demonstrated in several studies [38][39][40][41]. In the SCAMP period, utilization of this test decreased to ∼3 % of patients.…”