Quality statement 1: Initial assessment – recording the event, clinical history and physical examination

Quality statement

People who have had a suspected transient loss of consciousness have an initial assessment to record details of the event, clinical history and physical examination.

Rationale

If a suspected transient loss of consciousness has occurred, it is important to collect information as soon as possible from the person and especially from any witnesses. This is critical in confirming whether or not a transient loss of consciousness has occurred, and in establishing relevant features of the event, so that patients can be directed along the correct care pathway.

Inadequate assessment may result in inappropriate care that may be costly, ineffective and possibly harmful. It is also important to record current medications, to identify any medication that may have caused or contributed to transient loss of consciousness, and identify any 'red flag' signs or symptoms (see quality statement 3).

Quality measures

Structure

Evidence of local arrangements to ensure that people who have had a suspected transient loss of consciousness have an initial assessment to record details of the event, clinical history and physical examination.

Data source: Local data collection.

Process

(a) Proportion of people with a suspected transient loss of consciousness who have the details of the event recorded.

Numerator – the number in the denominator who have the details of the event recorded.

Denominator – the number of people with a suspected transient loss of consciousness.

Data source: Local data collection.

(b) Proportion of people with a suspected transient loss of consciousness who have the details of the clinical history and physical examination assessment recorded.

Numerator – the number in the denominator who have the details of the clinical history and physical examination assessment recorded.

Denominator – the number of people with a suspected transient loss of consciousness.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (first‑line staff such as paramedic and emergency service staff, GPs, and out‑of‑hours staff) ensure that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.

Healthcare professionals ensure that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.

Commissioners (NHS England area teams and clinical commissioning groups) ensure that they specify in contracts with ambulance and emergency services that people who have had a suspected transient loss of consciousness have an initial assessment, in which the details of the event are recorded, a clinical history is taken and a physical examination is carried out.

What the quality statement means for patients, service users and carers

People who have had a blackout have an assessment to find out more about the blackout and why it happened. This will involve recording details of the blackout (by witnesses) and any previous blackouts, medical history, family history of heart disease, and any medicines being taken, checking vital signs such as pulse rate, blood pressure, breathing rate and temperature, and also listening to the chest.

Source guidance

Definitions of terms used in this quality statement

Detailed account of the event

An account of the event should be taken from the person and any witnesses who are present at the initial consultation at the point of contact. Attempts should be made to contact any further witnesses (for example, by telephone).

The following details should be recorded:

  • circumstances of the event

  • person's posture immediately before loss of consciousness

  • prodromal symptoms (such as sweating or feeling warm or hot)

  • physical appearance (for example, whether eyes were open or shut, and the colour of the person's complexion during the event)

  • presence or absence of movement during the event (for example, limb‑jerking and its duration)

  • any tongue‑biting (record whether the side or the tip of the tongue was bitten)

  • injury occurring during the event (record site and severity)

  • duration of the event (onset to regaining consciousness)

  • presence or absence of confusion during the recovery period

  • weakness down 1 side during the recovery period.

[Adapted from NICE clinical guideline 109, recommendation 1.1.1.2]

Detailed clinical history and physical examination

Detailed clinical history and physical examination should involve recording the following:

  • details of any previous transient loss of consciousness events, including number and frequency

  • the person's medical history and any family history of cardiac disease (for example, personal history of heart disease and family history of sudden cardiac death)

  • current medication that may have contributed to transient loss of consciousness (for example, diuretics)

  • vital signs (for example, pulse rate, respiratory rate and temperature) – repeat if clinically indicated

  • lying and standing blood pressure if clinically appropriate

  • other cardiovascular and neurological signs.

[Adapted from NICE clinical guideline 109, recommendation 1.1.2.1]