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.