Evaluating and standardizing clinical management of patients presenting to a central London Emergency Department with dizziness

Despite growing evidence for these bedside procedures, vertigo management in ED remains sub-optimal. Our ED lacks an established pathway and standardised assessment for managing acute dizziness. Our aim was to review current assessment and management and recommend improvements in standardised care for patients with dizziness.

A retrospective ED clinical notes review was undertaken of adult presentations to ED, with either a primary complaint of dizziness or diagnosis of peripheral vestibulopathy (BPPV, vestibular neuritis, labyrinthitis, Meniere’s disease) between April-December 2021 (8-months). We extracted: diagnosis frequency; across-case counts of neuro-imaging, HINTS+, DHTs, and whether vestibular suppressant medication was prescribed.

1616 ED cases were reviewed. 401(24.8%) were diagnosed with peripheral vertigo, 150(9.2%) with stroke/TIA, while 244(15.1%) had no diagnosis. HINTS+ was completed in 125(7.7%) cases and DHT in 104(6.4%).

Of all ED cases, 150(9.3%) were diagnosed with labyrinthitis/neuritis, but HINTS+ was documented in only 36(24%).  Vestibular suppressant medication was prescribed in most cases - 103(68.6%). Most notably, of the 36 cases who had a HINTS+ documented, 22(61%) received a peripheral diagnosis despite no identifying factors on HINTS+.

Of the 401 peripheral vestibular cases, a diagnosis of BPPV was recorded for 232(57.9%) cases, despite only 65(28.0%) having a DHT completed. Epley manoeuvres were documented in 30(12.9%) cases, and vestibular medications were prescribed in 147(36.6%).

Neuro-imaging was completed in 212(13%) of all ED cases. 26(12.3%) patients were diagnosed with a stroke and 21(9.9%) BPPV.

Documentation of HINTS+ and DHT was extremely varied and challenging to interpret due to unstandardized reporting.

Results show the significant volume of patients presenting with dizziness in our ED. Our data correspond with other reports where cost-effective bedside tests to diagnose peripheral conditions are under-utilised. BPPV was apparently diagnosed without due testing, neuro-imaging was conducted unnecessarily, medications were prescribed inappropriately, and documentation of bed-side diagnostic tests lacked any standardisation for consistent, accurate interpretation.

Aim to secure funding for a service improvement project to design educational and practice development training to increase HINTS+ and DHT use in ED and define auditable standards to assure optimal clinical management for this patient cohort.