Do Vestibular Physiotherapy and a Clinical Pathway in the Emergency Department Improve Management of Vertigo?

Objective Determine the effects of a vertigo/dizziness emergency department (ED) clinical pathway incorporating vestibular physiotherapy on quality and efficiency of care. Study Design A multisite retrospective study investigated differences between cohorts before and after a vertigo clinical pathway and cohorts who did and did not receive vestibular physiotherapy assessment. Setting Adults presenting to 2 Australian EDs with symptoms clinically consistent with vestibular disorder were captured via ED diagnostic code screening and subsequent medical record review. Methods Medical record audits obtained quality of care indicators: diagnosis, HINTS (head impulse-nystagmus-test of skew), and vestibular physiotherapy management. Linked hospital administrative data sets provided efficiency measures: time from ED presentation to assessments, hospital admission rates, and ED and total hospital length of stay. Results Postpathway cohorts (n = 329) showed greater use of HINTS (by 27%; 95% CI, 21%-33%), more frequent vestibular physiotherapy assessment (by 27%; 95% CI, 20%-33%), reduced wait time to assessment (25.0 to 4.6 hours; 95% CI, -27.1 to -14.1), and reduced ED length of stay (3.9 to 3.2 hours; 95% CI, -0.3 to -1.0) as compared with prepathway cohorts (n = 214). When compared with those not receiving vestibular physiotherapy assessment, patients assessed by a vestibular physiotherapist (n = 150) received a specific diagnosis more frequently (65% vs 34%; 95% CI, 22%-40%) but were admitted more often (79% vs 49%; 95% CI, 22%-38%) with longer total hospital length of stay (13.0 vs 5.0 hours; 95% CI, 6.1-10.6). Conclusion An ED vertigo clinical pathway was associated with improved quality and efficiency of care, including reduced ED time. Vestibular physiotherapist assessment was associated with greater diagnostic specificity but higher hospital admissions.