Come organizzare una “Syncope Unit”
Michele Brignoleg
SINCOPE2 0 1 1
Syncope management facilities:ESC standards
Optimal standard for quality service delivery:1- Cohesive, structured care pathway - either
d li d ithi i l f ilit
Optimal standard for quality service delivery:
delivered within a single syncope facility or as a more multi-faceted service.
2- Adoption of standardized guidelines-basedapproach for:pp• diagnostic criteria • diagnostic work-up g p• risk stratification • treatment
ESC Guidelines on Management of Syncope
Syncope management facilities:ESC standards
Wh t
ESC standards
Who must managesyncope patients?syncope patients?
The Syncope ExpertThe syncope expert is a single physician or the team of physicians who lead the process of a comprehensive management of the patient from risk stratification to diagnosismanagement of the patient from risk stratification to diagnosis, therapy and follow-up. They usually perform directly the core laboratory tests and have preferential access to hospitalization
d th di ti t t d t l thand any other diagnostic test and eventual therapy.
ESC Guidelines on Management of Syncope
Come organizzare una Syncope UnitCome organizzare una Syncope Unitnel Tuo ospedale:
i criteri GIMSI per la certificazionei criteri GIMSI per la certificazione
Michele Brignoleg
www.gimsi.it
Certificazione GIMSI:Certificazione GIMSI:• Come ottenerla ?• Perché ?
www.gimsi.it
continua
seguesegue
Le S ncope Unit certificate GIMSI nel 2009Le Syncope Unit certificate GIMSI nel 2009:ALESSANDRIABOLZANOCATANIACATANIACENTOCOMOEMPOLI
iFIRENZE ‐ CareggiFIRENZE ‐ Nuovo s. Giovanni di dioFIRENZE ‐ S. Maria nuovaGENOVAGENOVALAVAGNAMESTREMILANO ‐ NiguardaMODENAMODENAMONCALIERINAPOLI – Federico IIOSTIAOSREGGIO EMILIAROMA – S Filippo NeriSERIATETRENTOTRENTO
www.gimsi.it
Le Syncope Unit certificate GIMSI
Le Syncope Unit certificate GIMSI2011 (totale = 47)
AVELLINOy2009 (totale = 21)
ALESSANDRIA
AOSTABARI – UniversitàBARI ‐ Policlinico
BENTIVOGLIOALESSANDRIABOLZANOCATANIACENTOCOMO
BERGAMOBRESCIA
CARRARACASARANO
COMOEMPOLIFIRENZE ‐ CareggiFIRENZE ‐ Nuovo s. Giovanni di dioFIRENZE ‐ S Maria nuova
CATANZAROCONEGLIANO V.
COSENZAFIRENZE – SM Annunziata
GENOVA S M iFIRENZE ‐ S. Maria nuovaGENOVA‐ V ScassiLAVAGNAMESTREMILANO ‐ Niguarda
GENOVA – S. MartinoIMPERIAMASSA
GROSSETOMILANO ‐ NiguardaMODENAMONCALIERINAPOLI – Federico IIOSTIA
MERCATO S. SEVERINOMILANO – Maugeri
MONTESCANONAPOLI – II UniversitàOSTIA
REGGIO EMILIAROMA – S Filippo NeriSERIATETRENTO
NAPOLI II UniversitàORBASSANOPINEROLORAVENNATARANTOTRENTO
www.gimsi.it
TARANTOTRADATE
SINCOPE2 0 1 1
Le Syncope Unit certificate GIMSI 2011(totale = 47)
Geriatria
Medicina Interna
Medicina d’UrgenzaMedicina d Urgenza
Neurologia
MultidisciplinareMultidisciplinare
Cardiologia
Syncope Unit Project (SUP) Syncope Unit description (n=9)
Personnels(no.)
Syncope experts #1 in 4 Unitsy p p#2‐4 in 5 Units
Staff #2 in 6 UnitsStaff #2 in 6 Units#>2 in 3 Units
Brignole et al. Europace 2010; 12: 109–118
Volume per centre (patients per month)50th25th 75th maxmin
11ni
ts 20
9
ope
U
12
15
Syn
co
13
28
S
23
28
15 23129 28
23
Number of patientsBrignole et al. Europace 2010; 12: 109–118
Volume per centre(patients per 100,000 inhabitants per year)
50th25th 75th max50th25th 75th max
43Old Unit
R t U it
its 163
57Recent Unit
pe U
n
64
71
ynco
p
132
64
S
220
63
71 1636343 220
181
Number of patients71 1636343 220
Brignole et al. Europace 2010; 12: 109–118
Volume per centre(patients per 100 000 inhabitants per year)(patients per 100,000 inhabitants per year)
M Whit t t 0 03
163160
180Mann‐Whitney test: p=0.03
163120
140
60
80
100
6020
40
60
0
Old Units Recent Units
Brignole et al. Europace 2010; 12: 109–118
Syncope Unit Project (SUP) Management
Referral source
In‐hospital
16%
Out‐hospital13% 60%
Protected discharge
Emergency11%
Emergencyroom
Brignole et al. Europace 2010; 12: 109–118
SUP data in perspectivesSyncope Unit Project (SUP)
Syncope visits per 100,000 inhabitants/year y p p , /yin different settings
General practice 930Emergency room 379SSyncope Unit 163
Certificazione GIMSI:Certificazione GIMSI:• Come ottenerla ?• Perché ?
www.gimsi.it
Perché certificazione GIMSI (1):Perché certificazione GIMSI (1):
• Seguire gli standard proposti dal GIMSI fa• Seguire gli standard proposti dal GIMSI fa migliorare la qualità dell’assistenza
www.gimsi.it
Diagnostic yield
Historical, non‐standardized 42% ‐ 54% Kapoor. N Engl J Med 1983Li ( t ti i ) AHistorical, non standardized
(best clinical practice)42% 54% Linzer (systematic review). Ann
Intern Med 1997Ammirati. G Ital Cardiol 1999Getchell. J Gen Intern Med 1999D l G It l H t J 2003Del Greco. Ital Heart J 2003
Standardized protocols(Syncope facilities)
17% ‐ 24% Ammirati. Eur Heart J 2000Alboni. J Am Coll Cardiol 2001Sarasin. Am J Med 2001(Syncope facilities)Blanc. Eur Heart J 2002Chen. Mayo Clin Proc 2003Shen. Circulation 2004Brignole. Europace 2009g p
Structured algorithms(interactive web‐based,
2% ‐ 5% Brignole. Eur Heart J 2006Brignole. Europace 2006
remote tutoring)
Knowing the mechanism is a pre‐requisite for preventing future recurrences and related morbidity
Diagnostic yield
Historical, non‐standardized 42% ‐ 54% Kapoor. N Engl J Med 1983Li ( t ti i ) AHistorical, non standardized
(best clinical practice)42% 54% Linzer (systematic review). Ann
Intern Med 1997Ammirati. G Ital Cardiol 1999Getchell. J Gen Intern Med 1999D l G It l H t J 2003Del Greco. Ital Heart J 2003
Standardized protocols(Syncope facilities)
17% ‐ 24% Ammirati. Eur Heart J 2000Alboni. J Am Coll Cardiol 2001Sarasin. Am J Med 2001(Syncope facilities)Blanc. Eur Heart J 2002Chen. Mayo Clin Proc 2003Shen. Circulation 2004Brignole. Europace 2009g p
Structured algorithms(interactive web‐based,
2% ‐ 5% Brignole. Eur Heart J 2006Brignole. Europace 2006
remote tutoring)
K i th h i i i it f tiKnowing the mechanism is a pre‐requisite for preventing future recurrences and related morbidity
Perché certificazione GIMSI (2):Perché certificazione GIMSI (2):
• Lo studio SUP ha confermato che seguire gliLo studio SUP ha confermato che seguire gli standard proposti dal GIMSI fa migliorare la qualità dell’assistenza
www.gimsi.it
AIACAssociazione ItalianaAritmologia eC di ti l i
Syncope Unit ProjectCardiostimolazione
Syncope Unit ProjectA prospective systematic guideline-based evaluation andA prospective systematic guideline based evaluation and
treatment of patients referred to the Syncope Units of general hospitalsgeneral hospitals
Brignole et al. Europace 2010; 12: 109–118
An official study of Associazione Italiana di Aritmologia eAn official study of Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC)
Syncope Unit Project (SUP) Methods
• Ob ti l ti i t f• Observational prospective registry from 9 Italian Syncope Units
• Consecutive patients from March 15th to September 15ht 2008to September 15ht, 2008
Syncope Unit Project (SUP) Management
Diagnostic flow
941
50 (5%)
Eligible
Not e al able50 (5%)
Analyzed 891
Not evaluable
191 (21%)Diagnosis madeat initial evaluation 1.2±1.5 testsat initial evaluation
541 (61%)Early diagnosish 2.8±1.6 tests( )
with investigations
159 (18%)No diagnosis
2.8±1.6 tests
159 (18%)No diagnosis(follow‐up) 3.5±1.8 tests
Syncope Unit Project (SUP) Management
Performed Diagnostic NND
Diagnostic yield (n=700 pts)g
Tilt testing 443 53% 1.9EP study 40 35% 2.9In-hospital ECG monitoring 80 17% 5.7Carotid sinus massage 509 12% 8.2Holter monitoring 166 9% 11Coronary angiography 14 7% 14Brain CT scan and/or MRI scan 73 7% 15Brain CT scan and/or MRI scan 73 7% 15EEG 34 6% 17Echocardiogram 269 3% 34Exercise test 41 2% 41Basic blood chemistry tests 298 2% 60Total number of tests 2006 18% 5.4Mean n° of tests per patient 2.9±1.8 - -
Syncope Unit Project (SUP) Management
28%
58%60%
75%
Echocardiogram
Tilt testing
15%
38%
28%
43%
53%
24‐hour Holter
Blood tests
c oca d og a
4%
6%
15%
8%
21%
EEG
CT scan/MRI
New units
5%
4%
5%
7%
9%
EP study
Exercise testNew units
Old units
0%
1%4%
5%
ELR
Coronary angio1
6%
80%1%
57%
ILR
Carotid sinus massage
6%
0 20 40 60 80 100
ILR
Syncope Unit Project (SUP) Management
Case mix
Orthostatichypotension
CardiacArrhythmia
StructuralCardio-P l
Non-syncopalReflex yp y Pulmonary
1 2 3 4 5• Vasovagal• CSS• Situational
• Classical OH form
Delayed OH
• BradySick sinusAV blockPM dysf
T h
4• ACS• Aortic
Stenosis• Atrial
5• Metabolic• Epilepsy• Intoxications
* Situational
• Atypical• Likely reflex
• Delayed OH form (progressive)
• TachyVTSVT
• High risk of SCD
Atrial myxoma
• Pulmonary embolism
• Others
• Drop-attacks• Psychogenic • TIA• Falls
SCD • Others Falls
67% 4% 5% 1% 5%
Unknown Cause = 18%
Perché certificazione GIMSI (3):Perché certificazione GIMSI (3): • Attesta che la Tua Syncope Unit ha organizzazione e struttura standardizzata in accordo con le raccomandazioni della SEC• Dà visibilità alla Tua Syncope Unit a livello locale (pazienti, colleghi, ecc)• Dà visibilità alla Tua Syncope Unit a livello nazionale (sito web GIMSI, organizzazione Corsi GIMSI regionali, ecc)
Ti i t t ti i t ll ti d l i t• Ti aiuta a tenerti aggiornato sulla gestione del paziente con sincope• Ti dà l’opportunità di partecipare attivamente al Registro GIMSITi dà l opportunità di partecipare attivamente al Registro GIMSI
www.gimsi.it
SINCOPE2 0 1 1
pertanto…..
Se pensi che il tuo ospedale ha i requisiti, fai subito domanda direquisiti, fai subito domanda di certificazione. Sarà valutata e certificata già nel corso delSarà valutata e certificata già nel corso del 2011
www.gimsi.it
Top Related