Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project

摘要

Objectives:Isolated acute vestibular syndrome (iAVS) presentations to the emergency department (ED) pose management challenges, given the concerns for posterior circulation strokes. False-negative brain imaging may erroneously reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS.Methods:We launched an institutional Quality Improvement initiative, using DMAIC methodology. The outcome measures proportion of iAVS subjects who had HINTS-plus examinations and underwent neuroimaging by computed tomography/magnetic resonance imaging (CT/MRI) were compared before and after the established intervention. The intervention consisted of formal training for neurologists and emergency physicians on how to perform, document, and interpret HINTS-plus and implementation of novel iAVS management algorithm. Neuroimaging was not recommended if HINTS-plus suggested peripheral vestibular etiology. If a central process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved only for thrombolytic time-window cases.Results:In the first 2 months postimplementation, HINTS-plus testing performance by neurologists increased from 0 to 80 (P=0.007), and by ED providers from 0 to 9.09 (P=0.367). Head CT scans were reduced from 18.5 to 6.25. Brain MRI use was reduced from 51.8 to 31.2. About 60 of the iAVS subjects were discharged from the ED; none were readmitted or had another ED presentation in the ensuing 30 days.Conclusions:Implementation of HINTS-plus evaluation in the ED is valuable and feasible for neurologists, but challenging for emergency physicians. Future studies should determine the dose-response curve of educational interventions.