Autonomic Dysfunction: Diagnosis and Management. Setting up and delivering a Syncope Service - Nicki Williams



In this on-demand teaching session, experienced healthcare professional Nikki Williams will share her journey and insights on setting up a Syncope Clinic in Mansfield. Attendees can expect valuable lessons for setting up their services, including understanding health care systems, developing staff resources, managing logistics, and implementing critical strategies for patient referrals and treatment. She will also touch upon challenges faced, including dealing with DVLA driving guidance and managing clinic room availability. As someone who is successfully managing arrhythmia and syncope services, Nikki offers real world advice and solutions to the issues faced when setting up a hospital department.
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Nicki has been in nursing for 24 years, starting her career in general medicine then moving into cardiology where she has worked for the last 20 years. She has worked on the wards, CCU and in the cardiac catheter lab.

A decade ago, Nicki was given the opportunity to shape the nurse led cardiac services in Mansfield and developed the chest pain service, and for the last 7 years, the rhythm management and syncope service.

Within the syncope service, Nicki has seen a lot of patients with autonomic dysfunction and her curiosity has led her to develop a special interest in this area.

She looks forward to sharing her knowledge and experience in setting up and delivering a Syncope Service.

Learning objectives

1. Understand the reasoning and benefits behind establishing a syncope clinic within a healthcare setting, including the potential to expedite diagnosis, treatment and increase patient safety. 2. Gain insight into the planning and resources needed for establishing a syncope clinic, covering staffing and material needs, appropriate space, and system supports. 3. Understand how to interpret guidance from relevant bodies (e.g., DVLA) and apply them in clinical practice, such as advising patients on their responsibilities relating to driving after experiencing an episode of syncope. 4. Learn strategies to collaborate effectively with various stakeholders (e.g., consultants, elderly care services, neurology services) to ensure that the clinic is comprehensive and provides optimal patient care. 5. Develop skills to manage potential challenges and sensitive situations that might emerge in the clinic, such as informing patients about driving restrictions and dealing with their reactions.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

So our next talk before the break is from Nikki Williams. Um our good colleague and nurse from up in Mansfield. So Nikki's been in nursing for 24 years um and started a career in general medicine um going into cardiology. Um she's worked on wards, coronary care and cardiac cath lab. And she had the opportunity to shape nurse led cardiac services locally in Mansfield, developing a chest pain clinic. And for the last seven years has been involved in arrhythmia management and syncope service. And of course, within the syncope service as all of us have found and we're also seeing, we see a lot of people with autonomic dysfunction. And so she's developed specialist interest in this area as a result of her experiences and we've got a technical glitch. So it'll just be a minute two. It's not working. Ok. Ok. Right. So, hi, everybody. Um hopefully you will get something from this. Um I'm not gonna cover what is syncope um and how to treat it. That's just been done. So lovely. But this is um a little bit of a journey really on what we did in my trust, setting up a syncope service and some hopefully um useful information for people that want to set up their own service. So, um the fainting goat is courtesy of my child that helped me with the technology. Um So why did we choose to set up a Syncope clinic? Um Syncope has a really high burden on our front door er facilities in secondary care. So around 3% and, and this was pre COVID data. Um I apologize for not having time to look at the current data, but experience I think tells us that actually it's higher than 3%. Now, my referrals have certainly escalated. Um around a third of those are admitted and for anything up to 123 days and half of those patients leave having had no tests and with no diagnosis. So it's questionable the value of those um bed days. Um half of the admissions are elderly and quite a lot of falls, like 10% of falls in elderly care are put or syncope, but that's missed because often there'll be an injury that takes priority in the initial assessments. Um uh it, it during that initial assessment and as we are an aging population, this is something that's only going to, we're going to see more of it. It's not the main cause. It's one of the um smaller er, things we see cardiac syncope, but you can't miss cardiac syncope because its risk of mortality is much higher. So, so all of these reasons. I thought our trust needs a syncope service. It's challenging, it's really hard to appropriately assess syncope in. There's a lack of expertise. Um It's busy. You can't do appropriate line standing blood pressures in an ed department. It's, it's difficult to spot red flags. You need to know what the red flags are. You need to know how to take an appropriate history for syncope. Um And a lack of a dedicated pathway in our trust for syncope meant these patients were getting lost. They'd we'd give them three days in hospital, discharge them with no active follow up and then they'd come back. So the benefits of a Syncope service were I was hoping we'd be able to reduce admissions that we would be able to expedite treatment and diagnosis and that our patients would just generally be safer. And the literature shows us that syncope units do reduce the burden on ed. They allow our emergency department and the rest of the hospital to flow better. Um And they do increase the likelihood of diagnosis and treatment. So my inspiration as a as a new arrhythmia nurse going to every possible teaching event that I caught from PRE COVID. There were lots of them. I was fortunate enough to attend a syncope symposium down in London. Um and listen to the team from James Cook University, talk about that. Um At the time, I was in awe of this amazing syncope service with all of these staff and excellent outcomes. And I thought we need to do something like this, but I work in a 600 bedded, you know, modest size D DH, I don't have all of these people, but I need to do something. What can I do? So, I looked at the guidelines, um, e se guidelines, I'm sure we're all familiar with them. They're um, really nicely written and the nice guidelines. And I thought, where do I start? What do I do? And um I really like to look at, you know, different areas of health care and different people and there's um partners in health. You might uh be familiar with an organization that look at addressing inequalities in global health care. They use this framework of this is the task we've got in hand. Have I got enough staff? Have I got the stuff I need to do it with? Do I have the space within to, to do this project and all the systems in place to support it moving forward? And when you're looking at what feels like a huge feet, look at where you are, look at where you want to be, work out the steps to get there and break it down into smaller chunks and then it doesn't feel as insurmountable and things become more achievable. So that's what I did looked at the staff. We were pretty staff poor compared to where my inspiration came from. It was me relatively inexperienced still learning but with oodles of enthusiasm and this was a new role. So also a little bit of something to prove. I had one part time secretary, our PPC patient pathway coordinator, one cardiologist that was prepared to supervise this six cardiologists that were very supportive, but a little bit more hands off and one cardiac physiologist and his team behind him. Um I realized at that point, I needed more people to help me. And um there's a way that I think he's really good in doing that. It's just really walking around the hospital singing the song that you want people to join in with you. And I'm popping out. Here's a little bit of a TED talk that explains that a little bit nicer. Oh Can we make that play? No? OK. Well, I'm not gonna do it. So basically, there's a man, there's a man stood there dancing on his own all by himself looking a little bit crazy. And that was me walking around the hospital. Have you heard of syncope? Would you like a syncope clinic? Can I help you? And then somebody joins him and copies in with his dance. So our elderly care consultant was I'd really like a Syncope clinic in this hospital. Yes, let's go ahead and do this. So we're dancing around the hospital and our cardiac physiologist was, that's a really good idea. Can I be involved? So the three of us are dancing, go away around the hospital and before we know it, I've got allies in stroke services, red consultants, care of the elderly neurology. And that was really special because we don't have on site neurology. They visit um from a neighboring hospital as you the neurology nurse specialist. So I just popped up into the neurology nurse's office. Hi, I'm Nick in Syncope Clinic. I, it's nice to see you can, we work together and, and, and that's how our service was formed. And then at the bottom there, I've got our divisional managers, heads of service and matrons. They're not involved in the clinical aspect of running it, but you cannot develop any service without those people on board because they will help you with your logistical side of things. So that was our staff, we were forming. Then there's the stuff you need, you need your obvious E CG machine, you need a compu that is my actual computer. You need BP and monitoring equipment and a pulse oximeter. So you don't actually need that much to start a Syncope Clinic. You do need access to all of the tests that Mel's talked through or the ability to refer for them. For instance, we don't do EP studies or cardiac um MRI at my trust, but I am able to refer directly for those we needed a pathway or something for people to know A that we existed and B how to get patients to us. So I put the guidelines into a nice flow chart with red flag symptoms. And this helped the staff in ed to appropriately restratify the patients they were seeing with syncope to decide. Did they need urgent review? Did they need to stay in? Could they discharge them knowing that they'd got the safety net of being seen within a syncope clinic imminently? And it was my aim to vet all referrals within 48 hours of receiving them. And I chose that if they're coming on a Friday afternoon, I'm not gonna see them till the Monday morning, but I did vet timely and the aim was to offer a clinic appointment within 14 days. I did manage to reach that target for about three weeks and then demand very quickly grew. We're now at about a four week. Wait, one thing I do want to, I didn't know quite where to put this in. So I've put it in with the stuff is the D VLA driving guidance. If you are running any kind of syncope clinic, we are duty bound. And this is straight from the the.gov website to know when we need to inform patients that they need to be letting the D VA know they've had this episode of syncope in whatever circumstance and advising the patient that they shouldn't be driving. So if you're not familiar with them, I would recommend that you have a, have a look and familiarize yourselves with the D VA guidance space. This is my actual clinic room. Um You need, it was very nice. I tied it up especially for this picture. Uh You need a computer access to all of the hospital systems that enable you to run a clinic, you know, an examination couch sink to wash your hands, all of the usual stuff. The issue isn't the room. The issue is access to the room. So I don't know what other people's clinics are. like. Clinic space is an absolute premium where I work. Everybody wants to do clinics. We've only got a, a finite amount of rooms. So my advice would be speak to the people that are in charge of that timetable. Make sure the timetable is up to date that people aren't booked in rooms that don't work and you trust and make sure that the time you have access to it is appropriate. So going back to driving my clinic used to be on a Friday afternoon telling H GV drivers they can't drive on a Friday afternoon in an abandoned clinic when you're the only person they're running isn't safe. People get angry, understandably, you know, they're frightened, there's livelihoods at stake. So we've moved our Syncope clinic to a Wednesday morning. My colleague does one on a Friday still, but we have security walking around and more clinic staff visible just um in case people sometimes forget themselves when they've received upsetting news systems. This is probably the most important um part of it. And where my naivety let me down a little bit. It's really important to make sure the logistic, you know, who is sending the appointment letters to the patients. What do they say? What do these letters say the training, identifying training needs and addressing them as you go along? So links in with consultants, links in with cardio, um other other centers that do syncope clinics to make sure we've got that governance. It's really important to have strong clinical governance in place, especially if you are new at something, taking a a service forward, audit and development and there'll be many other things that you all will think of that. I haven't put on that slide, but where were we? So before we started the pathway, we did a review of a three month period, 100 and 18 admissions to our hospital through Ed had come in coded syncope. The average length of stay was one syncopy 10 with non syncopal issues using the syncope pathway. 100 and six of those patients could have been discharged. So in three months, we could have saved 100 and six bed days. And I feel sure there would have been more if we'd have looked at some of the falls collapse query causes and some of the more nonspecific admission reasons through Ed. So I reviewed my data from March 19 to January 2020 shortly after that's when things went. Um Well, we all know So 72 patients were reviewed. A third of those presented with autonomic dysfunction. So I think I started the Syncope Clinic thinking I'm gonna pace the world. Everybody's gonna get a pacemaker. Um Or we, we're gonna pick up all these channelopathies. We're gonna find some regard and we're gonna, no, I spent most of my time telling people to drink more doing meds reviews, stopping bendroflumethiazide, all of these things. So we started to think a little bit differently that this is a syncope clinic. But also we're looking at more autonomic dysfunction. And we also saw some pots, all of those patients received lifestyle advice and only one of them represented to health care in the following. Well, today I checked the, I have these records, we checked them 7% of the patient of those 72 we still were treated and were paced. So yes, you do pick up cardiac syncope. But the figures obviously show that there's more orthostatic hypertension, hypotension out there. Sorry, some of the key learning. Um I kind of tried to put this into three sections and this is not all of the learning that occurred during setting up this service. So risk assessing the referrals of IOL, especially if you know, you're not going to be able to see that referral for a little bit of time because you can pick up red flags. So we have picked up somebody's got a, you know, an urgent pacing indication on their referral and EC G that's been picked up. We don't need to see them in clinic. We can refer straight for a pacemaker. So from a safety point of view, I prioritize referring uh reviewing those referrals, not all referrals are created equally and anybody that receives their own referrals for um vetting, you will know this. Some of them are awful collapsed. They're like, excellent. Can you give me some more information? So we've reviewed our referral system. Um I will give feedback on referrals if somebody repeatedly is sending less information than I would like. And now we were on that paper sheet that's still available for people for reference. But we've gone to full electronic referrals and that's better. I, you have to give me the information I need or you can't proceed with that referral. So fully electronic has made life easier. A much needed service will grow very quickly. And, and if I had some advice, it would be, don't open too many referral avenues so that you're snowed under with referrals, cos you will fail as a service. It's better to start small, learn with what you've got. Manage what you've got and grow your service with your referrals rather than collapse under the weight of them. Clinical practice. Mal touched on this assessment and history taking is absolutely key to this. It's some I learned very quickly that I thought I was good at taking a history. I wasn't, I'm better now um and always getting better but listen to your patient, they tell you what's wrong with them and if you haven't quite got what's wrong with them, you're perhaps not asking the right questions or you need to ask questions in a different way to elicit the information you want. I love it when they bring a witness with them that can tell you. Did they go pale? Did they go red? Were they sweaty? That helps put build the picture together in, in terms of syncope, identifying training needs but meeting them. It's alright me saying to my line manager, I really could do with knowing a little bit more about whatever it might be but not actively chasing that training, clinical governance and MDT meetings. I like to present patients at MDT every now and then. Not just the complex ones I think for me, it offers some quality assurance that I'm doing what I should be doing. Um And that just gives strength to um the service and reflective practice. I know we're not all just nurses but nurses are really good at reflective practice. It's what we're, it's how we're trained, it's what we do, but actual considered reflective practice is really important. I think when you're developing a new service and learning new skills as you go and with the audit and evaluation, I'm rubbish at this. It it's boring. I like the outcome of the facts and figures. I didn't enjoy collecting the data Um And I feel that my audit was the poor, poorer because of it. So I now have somebody that will help me with that, that quite likes doing those things. I would say the successes we've had within our service have been obviously um final treatment of pacemaker for some of the patients. But the learning about the autonomic dysfunction, seeing how significant the negative impact of that is on patients lives and the difference made when these people will have been struggling for a long time. Um It it will become apparent, the more you see these patients that actually the changes we can make is absolutely significant. And that's evident in the lack of representing to cardiology. And I was saying this morning, I don't know what the figures are for primary care, but I feel quite comfortable in saying, I suspect they aren't representing to primary care because the GPS would be very quick to send them back if symptoms were persisting these reduced presentations and save bed days, obviously bring us a cost saving element. There's a potential reduction in mortality there. So whilst nobody died from fainting, if you're 97 you faint and break your hip, your meta your, you know risk of, of um dying or not going to live independently again, is quite high patient satisfaction and job satisfaction a little bit. We've had lots of feedback, but I've chosen some of my favorites there for you to read. I felt heard and hopeful for the first time in years, I was upset. They stopped me driving, but I was happy, I got my pacemaker and I'd been collapsing for years and told it was normal. It's, we know it's not normal to, to repeatedly collapse. I knew it wasn't. And now I can live the life I want. And that's for me where job satisfaction comes in. And then one of our colleagues was saying that they feel comfortable knowing that they can discharge patients, knowing that they're going to be assessed. It, it removes that need to admit just in case some top tips, I had to learn to be very humble. It's not my service. It's the a service for the patients. I had to know what I didn't or learn what I didn't know very quickly and ask people to teach me be brave. It's difficult going into departments. You're not familiar with saying we've got this problem, we need to fix it. I think I know how to be persistent, be prepared to evaluate change, evaluate change as you go, every clinic was run differently for the first, you know, few sessions till we felt we were getting it right. And I might, we might not be a huge teaching hospital with numerous er members of the team at our disposal that we can dream big, start small and grow. Thank you.