Last year, we described a video-oculography-based remote Tele-Dizzy (TD) consultation service to improve diagnosis of acute vertigo in the ED. This year, we describe the results of this intervention.

Missed stroke in the ED is a leading cause of misdiagnosis-related harms. Diagnostic errors in acute dizziness/vertigo are frequent for both vestibular disorders (~80% misdiagnosed) and stroke (~35% missed).

This is a case study of a hospital-level quality improvement intervention. We deployed an ED TD consultation service to improve diagnosis of vertigo.

Since July 1, 2017, we have performed 231 consults at Johns Hopkins Hospital (JHH). We have seen improvements in diagnostic accuracy and reductions in unnecessary test utilization.

Accuracy: Without TD, the non-specific R42 “dizziness” ICD10 code diagnosis was made in 40% of all patients with dizziness/vertigo in 2015. Among those receiving a TD consultation, only 16.8% (n=39/231) were given a non-specific code - i.e., the number of symptom-only non-diagnoses was cut in half. 55% were given specific vestibular diagnoses (n=128/231) compared to a base rate of 8%.

Utilization: Without TD, the JH CT rate for all patients with vertigo in 2015 was 39%. With TD, only 2.2% (n=5/231) were recommended to receive a CT scan - i.e., reduction in CT rate of >90%. Without TD, the JH MRI rate for patients with dizziness or vertigo in 2015 was 20%. With TD, 19% (n=44/231) were recommended to receive a MRI - i.e., the rate of CTs was not reduced by simply ordering more MRI’s.

Our TD service has provided greater diagnostic accuracy and, simultaneously, lower utilization for patients who undergo consultation. Those who undergo neuroimaging receive the correct test (MRI), rather than an incorrect one (CT). Our next steps will be to expand our services to two community hospitals and test the hypothesis of lower risks of missed stroke, using a larger sample.