Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial
STUDY OBJECTIVE: We evaluated a strategy to increase use of the test Dix-Hallpike’s test [DHT]) and treatment canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department ED) dizziness visits.
METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation primary) head computed tomography CT) use length of stay admission and 90-day stroke events. The analysis was multilevel logistic regression with intervention month and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews.
RESULTS: We identified 7635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits 45/3077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits 159/4558; 95% confidence interval 3% to 4%; difference 2% 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits 44.0% [1352/3077] versus 36.9% [1682/4558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program.
CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use however were still low which relates in part to our broad inclusion criteria for dizziness visits.
Kerber K. A. D. L. McLaughlin T. Brown D. L. Burke J. F. Telian S. A. Tsodikov A. Fagerlin A. An L. C. Morgenstern L. B. Forman J. Vijan S. Rowell B. Meurer W. J. 2019). Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial. Ann Emerg Med. doi:10.1016/j.annemergmed.2019.09.017