Introduction

This quality standard covers the assessment, diagnosis and specialist referral of adults and young people (aged 16 and older) who have experienced a transient loss of consciousness. For more information see the topic overview.

Why this quality standard is needed

Transient loss of consciousness is very common, affecting up to half the population in the UK at some point in their lives. It is defined as spontaneous loss of consciousness with complete recovery. In this context, complete recovery would involve full recovery of consciousness without any residual neurological deficit. An episode is often described as a 'blackout' or a 'collapse', but some people collapse without transient loss of consciousness; this quality standard does not cover that situation. There are various causes of transient loss of consciousness, including cardiovascular disorders (which are the most common), neurological conditions such as epilepsy, and psychogenic attacks.

Approximately 3–5% of adults who attend accident and emergency departments do so because of transient loss of consciousness; this accounts for up to 6% of urgent hospital admissions. It is particularly common in people aged 65 and older; it has been estimated that up to 23% of this group experience syncope (transient loss of consciousness due to a reduction in blood supply to the brain) over a 10‑year period, and there is a high rate of recurrence. Reflex (vasovagal) syncope (which is usually benign) is common in younger people. Many younger people who have a vasovagal syncope episode may not seek medical help, so the true incidence of transient losses of consciousness – especially in younger people – is uncertain.

The diagnosis of the underlying cause of transient loss of consciousness is often inaccurate, inefficient and delayed. In addition, there is huge variation in the management of transient loss of consciousness. A substantial proportion of people initially diagnosed with and treated for epilepsy in fact have a cardiovascular cause for transient loss of consciousness. Some people have expensive or inappropriate tests, unnecessary referral or referral to the wrong specialty; whereas others with potentially dangerous conditions may not receive the correct assessment, diagnosis and treatment.

The aim of initial assessment, diagnosis and specialist referral of people who have had a transient loss of consciousness is to ensure that that they receive the correct diagnosis quickly, efficiently and cost effectively, leading to a suitable management plan for the underlying cause.

The quality standard is expected to contribute to improvements in the following outcomes:

  • Emergency hospital admissions.

  • Specialist referrals.

  • Mortality from causes considered preventable.

  • Patient experience of clinical care.

  • Misdiagnosis of the cause of transient loss of consciousness.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014/15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions

Reducing time spent in hospital by people with long‑term conditions

2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3a Emergency admissions for acute conditions that should not usually require hospital admission

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP out‑of‑hours services

4b Patient experience of hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving access to primary care services

4.4 Access to GP services

Improving children and young people's experience of healthcare

4.8 Children and young people's experience of outpatient services

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

Table 2 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality from causes considered preventable*

4.13 Health‑related quality of life for older people (Placeholder)

Alignment across the health and social care system

* Indicator shared with NHS Outcomes Framework (PHOF)

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to transient loss of consciousness.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services, which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience will not usually be included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact upon patient experience and are specific to the topic will be considered during quality statement development.

Coordinated services

The quality standard for transient loss of consciousness specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole transient loss of consciousness care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults and young people who have had a transient loss of consciousness in primary and secondary care settings.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of healthcare should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality transient loss of consciousness service are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults and young people who have had a transient loss of consciousness in primary and secondary care settings should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training will be considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults and young people who have had a transient loss of consciousness. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.