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Study Objective: 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., Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Strong evidence exists for diagnosing BPPV using the Dix-Hallpike Test (DHT) and treating it with the canalith repositioning maneuver (CRM). Despite this, both are infrequently used in the emergency department (ED)., Objective: As an early method to evaluate a BPPV-focused educational intervention, we evaluated whether an educational intervention improved ED provider performance on hypothetical stroke and BPPV cases delivered by vignette., Design: A randomized, controlled, educational intervention study in ED physicians. The intervention aimed to promote the appropriate use of the DHT and CRM. A BPPV vignette, a stroke-dizziness (safety) vignette, and vignette scoring schemes (higher scores indicating more optimal care) used previously established vignette methodology., Setting: We recruited participants at the exhibitor hall of an emergency medicine annual meeting., Participants: We recruited 48 emergency physicians. All were board certified or residency trained and board eligible. All were engaged in the active practice of emergency medicine. None were trainees., Interventions: Intervention group: a narrated, educational presentation by computer followed by the clinical vignettes., Control Group: Received no educational intervention and completed the clinical vignettes-intended to mirror current clinician practice., Main Outcome Measure: Primary endpoint: total score (out of 200 points) on a vignette-based scoring instrument assessing the performance of history, physical, and diagnostic testing on hypothetical stroke and BPPV cases., Results: The efficacy threshold was crossed at the interim analysis. The intervention group had higher performance scores compared with controls (113.2 versus 68.6, p < 0.00001). BPPV and safety subscores were both significantly higher in the intervention group. Sixty-two percent of the intervention group planned to use the DHT versus 29% of controls. After the vignette described characteristic BPPV nystagmus, 100% of the intervention group planned to use the CRM versus 17% of controls., Conclusions and Relevance: The educational intervention increased provider performance in dizziness vignettes, including more frequent appropriate use of the DHT/CRM. These findings indicate the intervention positively influenced planned behavior. Future work is needed to implement and evaluate this intervention in clinical practice.

Background: Benign 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/design: This 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., Discussion: If 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 Registration: ClinicalTrials.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.