Dumitrascu Oana M, Torbati Sam, Tighiouart Mourad, Newman-Toker David E, Song Shlee S
Departments of *Neurology †Emergency Medicine ‡Biostatistics and Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA §Departments of Neurology and Otolaryngology, The Johns Hopkins University School of Medicine, Baltimore, MD.
Neurologist. 2017 Mar;22(2):44-47. doi: 10.1097/NRL.0000000000000106.
Isolated acute vestibular syndrome (iAVS) presentations to the emergency department (ED) pose management challenges, given the concerns for posterior circulation strokes. False-negative brain imaging may erroneously reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS.
We launched an institutional Quality Improvement initiative, using DMAIC methodology. The outcome measures [proportion of iAVS subjects who had HINTS-plus examinations and underwent neuroimaging by computed tomography/magnetic resonance imaging (CT/MRI)] were compared before and after the established intervention. The intervention consisted of formal training for neurologists and emergency physicians on how to perform, document, and interpret HINTS-plus and implementation of novel iAVS management algorithm. Neuroimaging was not recommended if HINTS-plus suggested peripheral vestibular etiology. If a central process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved only for thrombolytic time-window cases.
In the first 2 months postimplementation, HINTS-plus testing performance by neurologists increased from 0% to 80% (P=0.007), and by ED providers from 0% to 9.09% (P=0.367). Head CT scans were reduced from 18.5% to 6.25%. Brain MRI use was reduced from 51.8% to 31.2%. About 60% of the iAVS subjects were discharged from the ED; none were readmitted or had another ED presentation in the ensuing 30 days.
Implementation of HINTS-plus evaluation in the ED is valuable and feasible for neurologists, but challenging for emergency physicians. Future studies should determine the "dose-response" curve of educational interventions.
鉴于对后循环卒中的担忧，孤立性急性前庭综合征（iAVS）患者到急诊科就诊给管理带来了挑战。脑成像假阴性可能会错误地让临床医生放心，而HINTS-plus检查在筛查iAVS中的卒中方面优于成像检查。我们研究了在急诊科实施HINTS-plus检测的可行性，旨在减少iAVS患者的神经成像检查。
我们采用DMAIC方法开展了一项机构质量改进计划。比较既定干预前后的结果指标（接受HINTS-plus检查并通过计算机断层扫描/磁共振成像（CT/MRI）进行神经成像的iAVS受试者比例）。干预措施包括对神经科医生和急诊科医生进行关于如何进行、记录和解释HINTS-plus的正式培训，以及实施新的iAVS管理算法。如果HINTS-plus提示外周前庭病因，则不建议进行神经成像检查。如果怀疑是中枢性病变，则进行脑部MRI/磁共振血管造影。头部CT仅保留用于溶栓时间窗病例。
在实施后的前两个月，神经科医生进行HINTS-plus检测的比例从0%提高到80%（P = 0.007），急诊科医生进行检测的比例从0%提高到9.09%（P = 0.367）。头部CT扫描比例从18.5%降至6.25%。脑部MRI的使用比例从51.8%降至31.2%。约60%的iAVS受试者从急诊科出院；在随后的30天内，无人再次入院或再次到急诊科就诊。
在急诊科实施HINTS-plus评估对神经科医生来说是有价值且可行的，但对急诊科医生来说具有挑战性。未来的研究应确定教育干预的“剂量反应”曲线。
