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.