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Three Part Question

In [patients presenting to the ED with a syncopal episode] does [a low risk clasification from the San Francisco Syncope Rule] allow [a safe discharge from the ED for community follow up] ?

Clinical Scenario

Patient attends the emergency department following an episode of collapse with no obvious cause. How should you assess the suitability for in/ out patient management? How successful is the San Francisco syncope rule at highlighting the patients that are at risk of significant future events.

The San Francisco Syncope rule attempts to highlight those patients who are at risk of a serious outcome following an episode of syncope, by scoring the patients according to the outcomes of initial investigations. The mneumonic often used to remember these is "CHESS" history of Congestive heart failure, Hematocrit <30%, abnormal ECG, a patient complaint of Shortness of breath, and a systolic blood pressure <90 mm Hg.

Search Strategy

NHS Evidence Databases; MEDLINE, CINAL, EMBASE.
MEDLINE; [exp SYNCOPE, VASOVAGAL/ OR exp SYNCOPE/OR Faint OR Blackout OR collapse] AND [(San AND Francisco AND syncope AND rule) OR exp RISK ASSESSMENT/ OR exp RISK FACTORS/ OR exp DIAGNOSTIC TESTS, ROUTINE] AND [EMERGENCY SERVICE, HOSPITAL/ OR exp EMERGENCY MEDICAL SERVICES/]
CINAL; [exp SYNCOPE/ OR *SYNCOPE, VASOVAGAL/OR BLACKOUT OR FAINT OR COLLAPSE] AND [CLINICAL ASSESSMENT TOOLS/ OR *RISK ASSESSMENT/OR(San AND Francisco AND syncope AND rule)] AND [EMERGENCY MEDICAL SERVICES/ OR exp EMERGENCY SERVICE/]
EMBASE; [SYNCOPE, VASOVAGAL/ OR exp SYNCOPE/OR Faint OR Blackout OR collapse] AND [RISK ASSESSMENT/ OR exp RISK FACTORS/ OR exp DIAGNOSTIC TESTS, ROUTINE/] AND [EMERGENCY SERVICE, HOSPITAL/ OR exp EMERGENCY MEDICAL SERVICES/]
All searches were limited to English Language and Adult patients.

Search Outcome

All 3 serches combined; with duplicate results discounted, 80 papers were returned.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
James Quinn, Daniel McDermott, Ian Stiell, Michael Kohn, George Wells, 2004	684 patients	prospective cohort study	Sensitivity of 96% (C.I. of 95%; 92-100%)	3 patients of low risk had serious outcomes.	7 day out comes only. Wide range of inclusion criteria: Including patients with Seizures and Chest Pain.
James Quinn, Daniel McDermott, Ian Stiell, Michael Kohn, George Wells, 2005 America	684 patients	prospective cohort study comparing SFSR to phycician assessment	Sensitivity of 96% (C.I. of 95%, 92-100%))	Admissions would have been 10% lower using this rule, without missing any high risk patients.	184 patients had other reasons for attending the ED. Scope was wider, to include chest pain patients.

References

1. James Quinn, Daniel McDermott, Ian Stiell, Michael Kohn, George Wells, Derivation of the San Francisco Syncope Rule to predict patients with Short Term serious outcomes Annals of Emergency Medicine 2004; 43; 224-232
2. James Quinn, Daniel McDermott, Ian Stiell, Michael Kohn, George Wells, San Francisco Syncope Rule vs Physician judgement and decision making. American Journal of Emergency Medicine 2005; 23; 782- 786