V. Stewart1,2, I. Rosbergen3, R. Grimley4,5
1The Prince Charles Hospital, Physiotherapy Department, Brisbane, Australia, 2Gold Coast University Hospital, Physiotherapy Department, Southport, Australia, 3Sunshine Coast Hospital and Health Service, Physiotherapy Department, Birtinya, Australia, 4Sunshine Coast Hospital and Health Service, Medical Services Division, Birtinya, Australia, 5Griffith University, School of Medicine, Brisbane, Australia
Background: Vertigo and dizziness are common presentations to the Emergency Department (ED) however are often not assessed or managed optimally. Vertigo and vestibular disorders are associated with substantial healthcare costs, and ongoing vestibular dysfunction has a significant impact on patients’ health and quality of life. Vestibular physiotherapy has excellent outcomes for peripheral vestibular disorders in the hospital setting, however has been underutilised in ED.
Purpose: To determine the effects of a vertigo clinical pathway incorporating vestibular physiotherapy assessment for patients presenting with vertigo or dizziness to the ED on quality and efficiency of care.
Methods: A multi-site, retrospective, pre-post cohort study investigated an ED vertigo clinical pathway. The pathway was developed by a multidisciplinary team with specialist expertise in vestibular disorders. Participants included all adults presenting to two Australian EDs with clinical features consistent with vestibular disorder in 6months before and after pathway introduction. Participants were identified by screening of ED diagnostic codes and subsequent medical record review. Medical record audits obtained quality of care indicators; use of Head-Impulse-Nystagmus-Test-of-Skew(HINTS); vestibular physiotherapy management. Linked hospital administrative datasets provided efficiency of care measures including hospital admission rates; ED and total hospital length of stay (LOS). Differences between pre and post clinical pathway cohorts, and patient cohorts who received and did not receive vestibular physiotherapy assessment were determined. Analysis included calculation of 95% confidence intervals for differences in binomial outcomes, and quartile regression for non-parametric length of stay data.
Results: A total of 543 patients were included, pre-pathway (N=214) and post-pathway (N=329). Following introduction of the pathway there was greater use of HINTS (by 27%; 95% CI 21, 33); more frequent vestibular physiotherapy assessment (by 27%; 95% CI 20, 33); reduced wait-time to assessment (from 25.0 to 4.6 hours; difference -20.4, 95% CI -27.1, -14.1); and reduced ED LOS (from 3.9 to 3.2hours; difference -0.7, 95% CI -0.3, -1.0hours). Compared to those not receiving vestibular physiotherapy assessment, patients assessed by vestibular physiotherapist (N=150) received a specific diagnosis more frequently (65% vs 34%; difference 31%, 95% CI 22, 40), but were admitted more frequently (79 vs 49%; difference 30, 95% CI 22, 38) and had longer total hospital LOS (13.0 vs 5.0hours; difference 8.1%; 95% CI 6.1, 10.6hours).
Conclusion(s): A vertigo clinical pathway in ED was associated with improved quality and efficiency of care including higher completion rates of vestibular assessments and reduced ED time. Vestibular physiotherapist review was associated with greater diagnostic specificity, but higher hospital admissions.
Implications: Implementation of hospital-specific ED vertigo clinical pathways may have positive effects on quality of care and efficiency of care for patients presenting to hospital with vertigo and dizziness.
Funding, acknowledgements: Nil
Keywords: Vestibular, Vertigo, Emergency
Topic: Service delivery/emerging roles
Did this work require ethics approval? Yes
Institution: The Prince Charles Hospital -Queensland Health
Committee: The Prince Charles Hospital Human Ethics Research Committee
Ethics number: HREC/14/QPCH/34
All authors, affiliations and abstracts have been published as submitted.
