Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.
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Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.

Kerber, Kevin A;Damschroder, Laura;McLaughlin, Thomas;Brown, Devin L;Burke, James F;Telian, Steven A;Tsodikov, Alexander;Fagerlin, Angela;An, Lawrence C;Morgenstern, Lewis B;Forman, Jane;Vijan, Sandeep;Rowell, Brigid;Meurer, William J;
Annals of emergency medicine 2019
270
kerber2019implementationannals

Abstract

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.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.We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 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% [1,352/3,077] versus 36.9% [1,682/4,558]). 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.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.

Keywords

snps transcription factors binding motifs ceu, northern europeans from utah crm, cis-regulatory module gwas, genome wide association studies ld, linkage disequilibrium mpra, massively parallel reporter assays: mpra pssm, position specific scoring matrix position specific scoring matrix roc, receiver operating characteristic rsat, regulatory sequence analysis tools regulatory variants snp, single nucleotide polymorphism sois, snps of interest tf, transcription factor tfbs, transcription factor binding site eqtl, expression quantitative trait loci rsid, reference snp identifier

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