# A Quality Improvement Project to Improve Syncope Care Through Structured Triage and Risk Stratification (STARS)

## TL;DR

This study shows that using a structured triage chart and education improved some aspects of syncope care but did not fully align with guidelines.

## Contribution

A quality improvement project implementing a Syncope Risk Stratification Chart and education to enhance guideline adherence in syncope care.

## Key findings

- Family history documentation improved significantly after the intervention.
- Admission rates for syncope patients remained largely unchanged despite the intervention.
- Telemetry use remained inconsistent with ESC guidelines even after the project.

## Abstract

Background

Syncope is a common emergency presentation, with causes ranging from benign reflex syncope to high-risk cardiac conditions. The 2018 European Society of Cardiology (ESC) Guidelines recommend structured risk stratification to guide admission and telemetry, but real-world adherence remains inconsistent.

Objective

This Quality Improvement Project (QIP) evaluated the impact of a structured Syncope Risk Stratification Chart (SRSC) and targeted education on guideline adherence, clinical assessment, and resource use in our Emergency Department and Medical Admissions Unit (MAU).

Methods

We conducted a retrospective review of syncope admissions (n=100, April-June 2024), followed by interventions (SRSC dissemination, staff education, visual prompts). A prospective re-audit (n=29, May-June 2025) assessed documentation of lying/standing blood pressure (LSBP) and family history (FH), admission rates, and telemetry use.

Results

In Round 1, admission rates differed significantly by ESC risk group (81% low-risk, 96% medium-risk, 100% high-risk; χ²(2, N=100) = 9.84, p = 0.007). In Round 2, rates were 89%, 89%, and 100%, with no significant differences (χ²(2, N=29) = 1.31, p = 0.52). Overall admissions were unchanged (92% vs 93%, p = 1.00). Telemetry allocation remained inconsistent (R1: 17%, 71%, 71%; R2: 38%, 88%, 91%), with between-round differences not statistically significant. Documentation improved, with LSBP recording increasing from 59% to 72% (p = 0.27) and FH assessment from 15% to 41% (p = 0.005).

Conclusion

Implementation of the SRSC and education significantly improved family history documentation and modestly improved LSBP recording. However, admission and telemetry practices remained misaligned with ESC recommendations. Sustained system-level strategies, senior triage input, and integration of decision-support tools are needed to achieve consistent, guideline-based syncope care.