Vertigo In Emergency Department Research Articles

Ventricular tachycardia as a rare and fatal cause of recurrent dizziness in emergency department

Ventricular tachycardia as a rare and fatal cause of recurrent dizziness in emergency department

Abstract 46: Cumulative Incidence Of Stroke Disability/mortality Following Emergency Department Discharge For Dizziness

Introduction: Providers are often concerned about missing stroke in Emergency Department (ED) dizziness visits. Prior studies found that the cumulative incidence of stroke after ED discharge for dizziness is low. However, little is known about the magnitude of disability and/or severity of subsequent strokes which is important for informing the scope of the problem. We aimed to estimate the cumulative incidence of stroke-disability/mortality following ED dizziness visits that were discharged home. Methods: We conducted a retrospective cohort study from January 2016 to December 2020 across 13 EDs within Kaiser Permanente Southern California (KPSC). We included all index visits for adults who were discharged home from the ED after a primary dizziness visit, excluding those with DNR/hospice status, trauma, or index stroke diagnosis. Post-stroke disability/mortality - defined as stroke hospitalization not discharged home - was captured over a 30-day follow-up period. Cumulative incidence of stroke-disability/mortality was calculated using Kaplan-Meier estimates censored for non-stroke death. Acute stroke management was also summarized. Results: We identified 77,315 index dizziness visits discharged home from the ED. Median age was 59 years (IQR,44-71) and 62% were female. The 30-day cumulative incidence of stroke-hospitalization was 0.12% (95% CI 0.10-0.15%; 1 in 823) and the cumulative incidence of post stroke-disability/mortality was 0.04% (95%CI 0.03-0.06; 1 in 2,342). At the subsequent stroke-hospitalizations, the frequency of acute interventions was as follows: 3% (3/94) intra-arterial thrombolytics, 5% (5/94) thrombectomy, 2% (2/94) suboccipital craniotomy, 3% (3/94) tracheostomy, 3% (3/94) gastrostomy, 10% (9/94) mechanical intubation. Conclusions: The cumulative incidence of post stroke-disability/mortality among patients discharged from the ED for dizziness is low and acute interventions used to manage severe strokes were infrequent. These data are important for planning studies to optimize outcomes of patients presenting to the ED for dizziness.

Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department.

Purpose: Routine head and neck CTAs (CTAhead+neck) performed for dizziness in the Emergency Department (ED) has steadily increased, but its clinical utility is still poorly elucidated. Our purpose was to assess the radiologic outcomes of CTAhead+neck in ED dizziness patients.Methods: ED dizziness patients with CTAhead+neck from January 2010 through November 2019 were retrospectively identified and further stratified into central vertigo (CV), peripheral vertigo (PV), and non-specific dizziness (NSD) groups by final clinical diagnoses. Findings on CTAhead+neck (vessel stenosis >50%, occlusion, dissection, and infarct), and infarct on subsequent MRI if performed, were assessed. Differences in imaging findings were analyzed using chi-square or Fisher's exact tests.Results: Of 867 dizziness patients, 88 were diagnosed with CV, 383 with PV, and 396 with NSD. On CTAhead+neck, 11.4% of all patients had posterior CTA findings, including posterior occlusions (4.2%), dissections (1.2%), and infarcts (2.3%). CV patients had more posterior circulation findings (31.8%) versus PV (9.9%) and NSD (8.3%) patients (both p < 0.01). 21.6% of CV patients had acute infarcts on CT versus none for PV and 0.03% for NSD patients (both p < 0.01). On MRI, 46.6% of CV patients had acute posterior circulation infarcts versus none for PV and 0.3% for NSD patients (p < 0.01).Conclusion: Diagnostic yield for CTAhead+neck for dizziness patients is low except in central vertigo patients which constitute only 1/10th of CTAs performed. Our single institution results support that CTAhead+neck is likely low-yield in patients with high clinical suspicion for PV or NSD and further studies are needed to test this hypothesis.

Risk Factors and Risk Model Construction of Stroke in Patients with Vertigo in Emergency Department.

Objective We aimed to explore the risk factors of stroke in patients with vertigo in the emergency department and establish a risk prediction model for stroke patients. Methods A total of 301 patients experiencing vertigo in our hospital from January 2020 to January 2021 were retrospectively included. Patients were divided into the stroke group (n = 56) and the nonstroke group (n = 245). The clinical characteristics of patients in both groups were collected and compared, followed by binary logistic regression that was employed to determine the risk factors that affect stroke diagnosis. The receiver operating characteristic (ROC) curve was used to clarify the effectiveness of the constructed model. Results Patients in the stroke group were older and had higher systolic and diastolic blood pressure on admission than the nonstroke group. Meanwhile, they demonstrated a higher proportion of diabetes and atrial fibrillation and focal muscle weakness, dysarthria, dysphagia, or ataxia in neurological examinations compared to the nonstroke group (all P < 0.05). The proportion of patients in the nonstroke group who had a history of vertigo or inner ear disease was significantly higher than that in the stroke group (P < 0.05). The patient's age ≥ 60 years old (OR = 3.57), diabetes (OR = 4.57), atrial fibrillation (OR = 4.26), previous history of vertigo or inner ear disease (OR = 0.16), focal muscle weakness (OR = 4.34), and dysphagia or ataxia (OR = 4.08) were associated with a higher risk of stroke. The area under the curve for stroke was 0.87, and the sensitivity and specificity were 98.2% and 57.6%, respectively, as the sum of the assigned scores was greater than 3. Conclusions Age ≥ 60 years old, diabetes, atrial fibrillation, previous history of vertigo or inner ear disease, focal muscle weakness, dysphagia, or ataxia were associated with a higher risk of stroke. The risk model constructed based on our findings may help to assess the risk of stroke in patients with vertigo in the emergency department.

Benign paroxysmal positional vertigo in emergency department: How to treat?

Background: The treatment of benign paroxysmal positional vertigo (BPPV) has not been well studied. Many clinicians are indifferent about canalith reposition maneuvers and frequently prefer medical treatments. Objectives: We aimed to detect efficacy of Epley maneuver in relieving symptoms of benign paroxysmal positional vertigo patients diagnosed in emergency department and if medical treatments are useful in patients whose symptoms were not relieved. Methods: The study was conducted as a prospective cohort study in the emergency department of a tertiary hospital. Patients who were over 18 years of age and presented to emergency department with complaints of vertigo symptoms and nausea and had a positive Dix–Hallpike test were included in the study. Patients’ demographic data, possible etiological factors, affected ear, and benign paroxysmal positional vertigo diagnosis in the history were recorded on the study data form. The European Evaluation of Vertigo scale and the Visual Analogue Scale (VAS) score of nausea and vertigo symptoms were graded and recorded for each patient before and after treatment. Results: Ninety patients were included in the study in total. Epley maneuver was carried out to all patients. Vertigo symptoms VAS (VASd) score (p &lt; 0.001), nausea and vomiting VAS (VASnv) score (p &lt; 0.001), and European Evaluation of Vertigo scale score (p &lt; 0.001) of all patients showed a statistically significant decrease after Epley maneuver. A combination of dimenhydrinate and metoclopramide helped to reduce VASd (p = 0.048), VASnv (p = 0.031), and European Evaluation of Vertigo scale scores (p = 0.001) at a statistically significant level more than dimenhydrinate treatment alone. Conclusions: Epley maneuver may be applied to every patient with benign paroxysmal positional vertigo. Dimenhydrinate and/or metoclopramide helps to control patients’ symptoms whose symptoms remain despite Epley maneuver.

Diagnosis of benign paroxysmal positional vertigo in Emergency Department: Our experience.

The Benign Paroxysmal Positional Vertigo (BPPV) represents the first cause of peripheral vertigo in populations and it is determined by a displacement of otoconial fragments within the semicircular canals. Following the patient’s head movements, these fragments, moving by inertia, incorrectly stimulate the canals generating vertigo. The BPPV is diagnosable by observing the nystagmus that is generated in the patient following the Dix-Hallpike maneuver used for BPPV diagnosis of vertical semi-circular canal, and, following the supine head yaw test used for lateral semi-circular canal. Correctly identifying the origin of this specific peripheral vertigo, would mean to obtain a faster diagnosis and an immediate resolution of the problem for the patient. In this context, this study aims to identify precise training activities, aimed at the application of specific diagnostic maneuverers for algorithm decisions in support of medical personnel. The evaluations reported in this study refer to the data collected in the Emergency Department of the Cardarelli Hospital of Naples. The results obtained, over a six-month observation period, highlighted the advantages of the proposed procedures in terms of costs, time and number of BPPV diagnoses.

Abstract TMP76: Ischemic Stroke Location and Vascular Risk in Dizziness Visits and The Follow-up Period: A Population-based Study

Objective: Prior studies found a concerning frequency of missed ischemic stroke among Emergency Department (ED) dizziness visits. We aim to describe details about the location of infarction (identified at ED dizziness visits or in the follow-up time period) and vascular risk. These data could inform opportunities to identify index strokes or reduce the risk of subsequent events. Methods: From October 2016 to April 2018, ED visits for dizziness, vertigo, or imbalance were identified in Nueces County, Texas. Validated index or subsequent 90-day ischemic stroke events were identified by linkage to the Brain Attack Surveillance in Corpus Christi (BASIC) project. Infarct locations were classified using imaging reports. The proportion of the events associated with Atherosclerotic cardiovascular disease (ASCVD) score ≥0.10, a common trigger for preventive therapy, was summarized. Results: There were 55 ischemic strokes identified at the time of the ED dizziness visit and 33 ischemic strokes identified in the subsequent 90-days. The Figure displays infarct location, days since ED visit, and ASCVD score. Posterior fossa infarction comprised 47% (26/55) (17 cerebellar, 9 brainstem) of the strokes identified at the dizziness visit and 39% (13/33) (11 cerebellar, 5 brainstem) of the strokes in the follow-up period. Baseline ACSVD scores were ≥0.10 in 78% (43/55) of patients with stroke identified at the dizziness visit and 79% (26/33) of patients with stroke identified in the subsequent 90-days. Conclusions: Posterior fossa lesions account a minority of the ischemic strokes that present to the ED with dizziness or occur in the subsequent 90-days. A substantial majority of these strokes have ASCVD scores higher than a common threshold for preventative therapies. Vascular risk assessment during ED dizziness visits might help providers to both diagnose acute strokes and to prompt preventative strategies in presumed non-stroke cases at increased risk for short-term stroke.

Cost of Neuroimaging of Patients with Vertigo in Emergency Department

Background and Aim: The fact that many diseases cause symptoms of vertigo and that some of them are life-threatening make it difficult to manage vertigo in emergency departments (ED). Parallel to these difficulties, the number of neuroimaging use in diagnosis is increasing. In this study, it is aimed to evaluate the neuroimaging costs of patients with vertigo in ED. Methods: The study was carried out with a retrospective review of the files of the patients with vertigo who were admitted to ED between 01.01.2013 and 31.12.2013. Patients were classified into 6 groups; central, peripheral, cardiac and blood pressure-induced, induced by internal causes, psychogenic, and vertigo related to other causes. Costs and the total cost of these groups were determined and the ratios were analyzed statistically. Results: Of the 381 patients; 31 (8.1%) patients were seen to be in the central, 175 (45.9%) in the peripheral vertigo. 72 of patients were seen to have been examined with computerized tomography (CT) and 35 with magnetic resonance imaging (MRI). Neuroimaging was observed to have been implemented mostly on the central induced group. The highest neuroimaging cost was in the peripheral vertigo group. However, when the cost per patient was calculated, the group with the lowest cost of each patient was the peripheral vertigo group. Conclusion: This study is the first study in Turkey for the cost analysis patients with a complaint of vertigo in ED. Avoiding unnecessary costs, along with the algorithms to be developed, can be possible with good and accurate patient management in ED.

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

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.

The role of transcranial Doppler ultrasonography in differential diagnosis of vertigo in the Emergency Department

Vertigo represents about 4% of access to the Emergency Department (ED). Several conditions, such as general medical illnesses, otovestibular diseases and neurological diseases (including posterior circulation stroke) cause acute vertigo. The incidence of cerebrovascular disease in patients with vertigo in ED varies from 3 to 5%. Although neurosonology studies on acute vestibular syndrome are scarce, the use of transcranial Doppler (TCD) and transcranial color Doppler (TCCD) in the management of vertigo patients has several advantages: it can be performed at the patient's bedside and repeated and, furthermore, its use is low-cost. In an acute stroke, with an experienced doctor, it can help distinguish an ischemic stroke from a hemorrhagic stroke. In acute central vertigo induced by posterior circulation stroke, the TCD or TCCD can be a screening test before angiographic neuroradiological studies for stenosis of vertebral or basal arteries. As a matter of fact, the clinical outcome, particularly in the posterior circulation stroke, is mainly related to a rapid diagnosis and subsequent treatment that will be able to quickly restore the blood flow. In conclusion, TCD and TCCD are useful in the differential diagnosis of vertigo in the ED, although we recognize the indisputable importance of clinical examination as a first step in vertigo management. In the evaluation of patients with acute central vertigo due to suspected posterior circulation stroke, the use of TCD or TCCD can rapidly reveal steno-occlusive disease of the posterior circulation, arterial dissections and give indirect signs of vertebra-basilar insufficiency.

Implementation of evidence-based practice for benign paroxysmal positional vertigo: DIZZTINCT\u2013 A study protocol for an exploratory stepped-wedge randomized trial

BackgroundBenign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized.Methods/designThis is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts.DiscussionIf this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts.Trial registrationClinicalTrials.gov, ID: NCT02809599. The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Benign paroxysmal positional vertigo may be the most common cause of dizziness in emergency department

Benign paroxysmal positional vertigo may be the most common cause of dizziness in emergency department

Stroke Risk after Nonstroke Emergency Department Dizziness Presentations: A Population-based Cohort Study: Kerber KA, Zahuranec DB, Brown DL, et al. Ann Neurol 2014;75:899−907.

Stroke Risk after Nonstroke Emergency Department Dizziness Presentations: A Population-based Cohort Study: Kerber KA, Zahuranec DB, Brown DL, et al. Ann Neurol 2014;75:899−907.

Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study.

Acute stroke is a serious concern in emergency department (ED) dizziness presentations. Prior studies, however, suggest that stroke is actually an unlikely cause of these presentations. Lacking are data on short- and long-term follow-up from population-based studies to establish stroke risk after presumed nonstroke ED dizziness presentations. From May 8, 2011 to May 7, 2012, patients ≥45 years of age presenting to EDs in Nueces County, Texas, with dizziness, vertigo, or imbalance were identified, excluding those with stroke as the initial diagnosis. Stroke events after the ED presentation up to October 2, 2012 were determined using the BASIC (Brain Attack Surveillance in Corpus Christi) study, which uses rigorous surveillance and neurologist validation. Cumulative stroke risk was calculated using Kaplan-Meier estimates. A total of 1,245 patients were followed for a median of 347 days (interquartile range [IQR] = 230-436 days). Median age was 61.9 years (IQR = 53.8-74.0 years). After the ED visit, 15 patients (1.2%) had a stroke. Stroke risk was 0.48% (95% confidence interval [CI] = 0.22-1.07%) at 2 days, 0.48% (95% CI = 0.22-1.07%) at 7 days, 0.56% (95% CI = 0.27-1.18%) at 30 days, 0.56% (95% CI = 0.27-1.18%) at 90 days, and 1.42% (95% CI = 0.85-2.36%) at 12 months. Using rigorous case ascertainment and outcome assessment in a population-based design, we found that the risk of stroke after presumed nonstroke ED dizziness presentations is very low, supporting a nonstroke etiology to the overwhelming majority of original events. High-risk subgroups likely exist, however, because most of the 90-day stroke risk occurred within 2 days. Vascular risk stratification was insufficient to identify these cases.

Use of BPPV Processes in Emergency Department Dizziness Presentations

A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use. Prospective population-based surveillance study. Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011. Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability. A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use. Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

Stroke: Highlights of Selected Articles

<i>Stroke:</i> Highlights of Selected Articles

The Use of the Dix-Hallpike Test and the Canalith Repositioning Maneuver in Emergency Department Dizziness Presentations: A Population-Based Study (P02.250)

Objective: To describe the use of the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM) in a population-based emergency department (ED) dizziness study. Background A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed with the DHT and treated with the CRM. No prior studies have assessed the use of these processes in ED dizziness presentations. Design/Methods: From January 15, 2008 to January 14, 2011, adult patients presenting to the ED in Nueces County, Texas, with dizziness, vertigo, or imbalance documented at triage were identified by review of ED logs, excluding those admitted to the hospital. Clinical information was abstracted from source documents. A hierarchical logistic regression model was fitted to estimate trends in DHT use and evaluate provider variability in DHT use. Results: 3,525 dizziness patients were identified. A DHT was documented in 137 visits (3.9%). The side tested was reported in 51 (37%). The DHT results were positive in 94 visits, negative in 37, and not documented in 6. Results were based on symptoms in 23, nystagmus in 21, and unknown in 93. None of the positive DHTs documented the characteristic pattern of BPPV nystagmus and only 47.9% (45 of 94) documented the affected side. A CRM was performed in only 8 visits. In the hierarchical model, every increase in month was associated with a 2% decrease in the use of the DHT (p=0.04), and the provider level explained more than 50% (ICC, 0.54) of the variance in DHT use. Conclusions: The DHT and CRM are used infrequently in this population. When documented, details about the technique and results are sparse. DHT use is decreasing over time, and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize the efficiency and effectiveness of care in ED dizziness presentations. Supported by: NIHK23RR024009. Disclosure: Dr. Kerber has received personal compensation for activities with Munson Medical Center, Weinberg Group, Estes, Ingram, Foels & Gibbs as a speaker and/or consultant. Dr. Meurer has nothing to disclose. Dr. Brown has received compensation and/or their research work has been funded, entirely or in part, by a grant to their university. The grant agreement requires that the name of the funding entity and the purpose of the grant may not be disclosed. The funding entity is a governmental organization. Dr. Lisabeth has nothing to disclose. Dr. Callaghan has nothing to disclose. Dr. Fendrick has received personal compensation for activities with Abbott Laboratories, Inc., ActiveHealth Management, GlaxoSmithKline, Inc., Hewitt Associates, MedImpact HealthCare Systems Inc., Merck & Co., Inc., Novartis, and Perrigo as a consultant. Dr. Fendrick has received personal compensation in an editorial capacity for The American Journal of Managed Care. Dr. Fendrick has received research support from AstraZeneca Pharmaceuticals, Pfizer Inc, and Sanofi-Aventis Pharmaceuticals, Inc. Dr. Morgenstern has nothing to disclose.

Emergency department documentation templates: variability in template selection and association with physical examination and test ordering in dizziness presentations

BackgroundClinical documentation systems, such as templates, have been associated with process utilization. The T-System emergency department (ED) templates are widely used but lacking are analyses of the templates association with processes. This system is also unique because of the many different template options available, and thus the selection of the template may also be important. We aimed to describe the selection of templates in ED dizziness presentations and to investigate the association between items on templates and process utilization.MethodsDizziness visits were captured from a population-based study of EDs that use documentation templates. Two relevant process outcomes were assessed: head computerized tomography (CT) scan and nystagmus examination. Multivariable logistic regression was used to estimate the probability of each outcome for patients who did or did not receive a relevant-item template. Propensity scores were also used to adjust for selection effects.ResultsThe final cohort was 1,485 visits. Thirty-one different templates were used. Use of a template with a head CT item was associated with an increase in the adjusted probability of head CT utilization from 12.2% (95% CI, 8.9%-16.6%) to 29.3% (95% CI, 26.0%-32.9%). The adjusted probability of documentation of a nystagmus assessment increased from 12.0% (95%CI, 8.8%-16.2%) when a nystagmus-item template was not used to 95.0% (95% CI, 92.8%-96.6%) when a nystagmus-item template was used. The associations remained significant after propensity score adjustments.ConclusionsProviders use many different templates in dizziness presentations. Important differences exist in the various templates and the template that is used likely impacts process utilization, even though selection may be arbitrary. The optimal design and selection of templates may offer a feasible and effective opportunity to improve care delivery.

Value of computed tomography scans in ED dizziness visits: analysis from a nationally representative sample

Objective The study aimed to assess measures of the clinical value of computed tomography (CT) scans in dizziness presentations at the aggregate level. Methods Using emergency department (ED) dizziness presentations captured in the National Hospital Ambulatory Medical Care Survey, the proportion of dizziness visits with a CT scan that received a central nervous system (CNS) diagnosis was measured yearly (1995-2004) and assessed for a trend over time. The independent association of having a CT scan with ED length of stay was examined using multivariable linear regression models. Results The proportion of dizziness visits with a CT scan that received a CNS diagnosis dropped 62% from 1995 to 2004 ( P < .05). By 2004, 94.1% (95% confidence interval, 89.4%-96.7%) of dizziness visits with a CT did not receive a CNS diagnosis. Having a CT scan was associated with a substantial increase in the length of stay with the effect modified by the number of other tests performed (range of increase, 40-77 minutes). Conclusion The clinical value of CT scans in dizziness presentations at the aggregate level may be very low and appears to have dropped over time. Computed tomography scans in the general dizziness population could also be an important contributor to ED length of stay. Use of CT scans in dizziness presentations should be a target for efforts to optimize the effectiveness and efficiency of care.