EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo

Prue Neely; Hemal Patel; John McTaggart; Stephen Bright; Tom Wellings

doi:10.1111/1742-6723.14124

EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo

Emerg Med Australas. 2023 Apr;35(2):312-318. doi: 10.1111/1742-6723.14124. Epub 2022 Nov 7.

Authors

Prue Neely^{1

2}, Hemal Patel^{2

3}, John McTaggart⁴, Stephen Bright², Tom Wellings⁵

Affiliations

¹ Physiotherapy Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia.
² Emergency Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia.
³ School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia.
⁴ Ci forum, Auckland, New Zealand.
⁵ Department of Neurology, Hunter New England Local Health District, Newcastle, New South Wales, Australia.

PMID: 36344257
DOI: 10.1111/1742-6723.14124

Abstract

Objective: To synthesise evidence-based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations.

Method: Current best practice models of care were synthesised into a single clinical, district-based peer-reviewed algorithm by a specialist focus group. An observational pre- and post-implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups.

Results: Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike-Dix performed by 27% (95% confidence interval [CI] 14-40%; defects pre-intervention 40%: post-intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2-30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18-48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15-45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post-project -4.23% (95% CI -7.20, -1.27%) (P = 0.041).

Conclusion: Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence-based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.

Keywords: BPPV; dizziness; emergency department; vertigo; vestibular.

MeSH terms

Benign Paroxysmal Positional Vertigo* / diagnosis
Benign Paroxysmal Positional Vertigo* / therapy
Dizziness* / therapy
Humans
Interrupted Time Series Analysis
Patient Positioning / methods