Best practice standards for the management of benign paroxysmal positional vertigo (BPPV) are not being followed in the ED.
A retrospective study in the regional NSW town of Wyong audited the medical records of 101 patients presenting with BPPV in the ED between 2017 and 2018.
The study, published in the Emergency Medicine Australasia, found positional testing for BPPV was performed in less than half the cases (45%) despite being a strong recommendation in guidelines.
“Of these patients who were appropriately diagnosed with BPPV via the Hallpike–Dix test, 41% (n = 19) (95% CI 28–56%) received a repositioning manoeuvre,” the study said.
“Repositioning manoeuvres were completed in 31% (n = 32) (95% CI 23–41%) of total BPPV patients.”
This compares favourably to 19% from an earlier Australian study in a metropolitan hospital.
Despite guideline recommendations against its use, radiographic imaging such as CT brain and CTA-ArchCOW was performed in 36% of patients diagnosed with BPPV.
Vestibular suppressant medication was administered as the sole therapeutic treatment in 58% of patients – again, in contradiction to guideline recommendations.
The average length of stay for BPPV in Wyong Hospital’s ED was 3.8 hrs with 24% of patients admitted to a ward.
“Of the patients who did not receive a repositioning manoeuvre in ED only 7% (n = 5) were referred on to either emergency or an outpatient physiotherapist to perform the recommended canalith repositioning manoeuvres.”
The investigators, led by Wyong Hospital’s senior emergency and advanced vestibular physiotherapist Prue Neely, said avoiding low value neuroimaging of patients with BPPV was a potential cost saving opportunity.
“Total Medicare Benefits Schedule imaging cost for peripheral dizziness in Wyong Hospital’s ED was $12 706.95 with $9736.45 directly related to imaging BPPV. When considering additional operational costs, this is a modest cost representation.”
As well, negative imaging could provide “false reassurance”.
“Considering the low diagnostic yield of head CT (6.9%) for patients presenting with isolated vertigo absent of focal neurological changes, clinicians can experience cognitive error when falsely reassured by negative acute imaging. This has the potential to lead to misdiagnosis and poorer patient outcomes.”
“It is apparent that clinician understanding of the pathogeneses, diagnosis and treatment of BPPV is not an isolated issue in EDs,” the study authors concluded.
“This poses an opportunity to improve clinical practice through education and implementation of clinical practice guidelines in the ED. Evidence based practice and reduced reliance on neuroimaging could potentially result in more cost effective care for patients presenting with peripheral dizziness.”