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The Newcastle Model

This is an example of a Rapid Access Falls and Syncope Service (FASS) for adults of all ages, but with the addition of particular expertise in the evaluation of older patients with these overlapping problems. The service was originally conceived and organised by Prof Rose Anne Kenny in 1991 until her return to Dublin in 2004, where she has since set up a Falls and Blackouts service in St James’ Hospital. Under Dr Steve Parry’s leadership, the Service has expanded considerably, with UK guidelines on tilt testing and the management of vasovagal syncope currently in press,1 and algorithms on the management of blackouts presenting to acute medical services recently published.2

The service model adopted by the Newcastle group is a rapid access multidisciplinary approach to referrals with blackouts and falls. Patients are seen on the “see, assess, treat and triage” model with as many investigations as possible completed at the initial “one-stop shop” assessment. FASS has a full range of tilt testing, beat-to-beat blood pressure monitoring and ambulatory monitoring equipment as well as physiotherapy, occupational therapy and specialist nursing expertise. All patients have an initial detailed assessment by a general physician, geriatrician or general practitioner with falls and syncope expertise, then are either managed at the Service or referred on to colleagues associated with the Service in neurology and neurophysiology, cardiology or ear nose and throat surgery, depending on the symptoms and the findings at the initial assessment.

There is a rapid access pathway for in-patients and for those attending the accident and emergency department, with recent innovations including a Rapid Access Ambulance Triage protocol and a further rapid access referral pathway from Social Service community carers. Recently, this group showed that activity at the acute hospital, at which the day case syncope evaluation unit was based, experienced in 1 year 6116 fewer bed days for the diagnostic categories comprising syncope and collapse, compared with peer teaching hospitals in the UK.3 This reduction translated into a significant saving in emergency hospital costs (4 million euros). The savings were attributed to a combination of factors: reduced re-admission rates, rapid access day case facilities for accident and emergency staff and community physicians, and reduced event rates because of effective targeted treatment strategies for syncope and falls.3 More recent work with newly developed algorithms has shown reductions in length of stay and number of in-patient admissions for those referred to acute medicine with falls and blackouts.4

References

  1. Parry SW, Reeve P, Lawson J, Shaw FE, Davison J, Norton M, Frearson R, Kerr SJR, Newton JL. The Newcastle Protocols 2008: An update on head-up tilt table testing and the management of vasovagal syncope and related disorders. Heart 2008 in press
  2. Parry SW, Newton JL, Frearson R, Tryambake P, Steen N, Kenny RA. Evidence-based algorithms and the management of falls and syncope in the acute medical setting. Clinical Medicine 2008;8(2):157-62
  3. Kenny RA et al, Impact of a dedicated syncope and falls facility for older adults on emergency beds. Age Ageing 2002; 31:272-5
  4. Brignole M et al, Guidelines on Management (Diagnosis and Treatment) of Syncope – Update 2004. Europace 2004; 6: 467-537