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Abstract Details

A Novel Tele-Dizzy Consultation Program in the Emergency Department Using Portable Video-Oculography to Improve Peripheral Vestibular and Stroke Diagnosis
Neuro-ophthalmology/Neuro-otology
S28 - Neuro-ophthalmology/Neuro-otology (3:41 PM-3:52 PM)
002
Missed stroke in the ED is a leading cause of misdiagnosis-related harms. The symptom most tightly associated with missed stroke is dizziness/vertigo. Diagnostic errors in acute dizziness/vertigo are frequent for both vestibular disorders (~80%) and stroke (~35%), due to the complexity of bedside evaluations, which rely heavily on subtle eye movement assessments. Lack of access to subspecialty expertise in real time is a major barrier.

We sought to deploy a tele-dizzy consultation service to improve diagnosis of acute dizziness and vertigo in the ED.

 


This preliminary case study of a systems-level quality improvement intervention included (1) defining a new care pathway; (2) securing leadership buy-in; (3) modeling quality and cost benefits; (4)implementing technology; and (5) identifying barriers and lessons learned.


Over two years we (1) Defined a care pathway for evaluating ED patients with dizziness/vertigo of suspected neurologic or peripheral vestibular etiology using portable video-oculography (VOG), with urgent clinic referrals for unclear cases; (2) Secured buy-in of ED Department Directors at 5 health system hospitals; (3) Modeled health system reduction of 50 missed strokes and ~$1 million per year saved on unnecessary imaging and admissions; (4) Implemented secure data platforms for eye movement recordings to be electronically transferred for review by clinical faculty using ‘store-forward’ telemedicine approach; (5) Identified need for culture change through local champions; faculty and fellow staffing to sustain service availability on evenings/weekends; and novel billing mechanisms in hybrid payment system (mixed population-based budgeted and fee-for-service). 172 tele-dizzy consultations resulted in 94 vestibular diagnoses. Rates of advanced neuroimaging recommended are less than half the base rate for advanced neuroimaging in the ED.

Bringing subspecialty expertise via tele-dizzy consultation using VOG-based rapid triage to EDs is feasible. The next step is to test the hypotheses of higher quality (greater diagnostic accuracy, fewer misdiagnosis-related harms) and lower costs.

Authors/Disclosures
Roksolyana R. Tourkevich, MD (Center for Neurosciences)
PRESENTER
No disclosure on file
Daniel R. Gold, DO (Johns Hopkins) Dr. Gold has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer . Dr. Gold has received publishing royalties from a publication relating to health care.
No disclosure on file
Anthony J. Brune III, DO (Memorial Healthcare Institute for Neuroscience) Dr. Brune has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Horizon Pharmaceuticals.
No disclosure on file
No disclosure on file
No disclosure on file
No disclosure on file
Mehdi Fanai, MD No disclosure on file
No disclosure on file
No disclosure on file
David S. Zee, MD (Johns Hopkins Hospital) Dr. Zee has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for florida legal. Dr. Zee has received publishing royalties from a publication relating to health care. Dr. Zee has received personal compensation in the range of $500-$4,999 for serving as a lectuer with u of pittsburg physical therapy. Dr. Zee has received personal compensation in the range of $500-$4,999 for serving as a lecturer with johms hopkins CME.
David E. Newman-Toker, MD, PhD, FAAN (Johns Hopkins Unversity School of Medicine, Dept of Neurology) The institution of Dr. Newman-Toker has received research support from NIH, AHRQ, AHA, Moore Foundation. Dr. Newman-Toker has received intellectual property interests from a discovery or technology relating to health care.