Management of Benign Paroxysmal Positional Vertigo: A Randomized Control Trial

Management of Benign Paroxysmal Positional Vertigo: A Randomized Control Trial Regina R. Sacco, DPT, BA, BHSc, David B. Burmeister, DO, Valerie Rupp, RN, MSN, CRNP, Marna Rayl Greenberg, DO, MPH Background: Benign Paroxysmal Positional Vertigo (BPPV) is a common complaint of patients who seek care in the Emergency Department (ED). Objective: To compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in ED patients with BPPV. In particular we sought to evaluate the improvement of vertigo in patients diagnosed with BPPV in the ED, assess their disposition time, and compare patient satisfaction between those patients who receive standard care vs. those who received vestibular rehabilitation. Methods: This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who present to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications as per provider preference, to alleviate their symptoms, including treatments such as benzodiazepines, antihistamines, and antiemetics, while the second group received a canalith repositioning maneuver. In both groups, the research staff assessed for symptom resolution every 15 minutes for the first hour, then every 30 minutes up to two hours or until symptom resolution or physician re-assessment was complete using a visual analog scale; one measuring dizziness and another to measure nausea. Phone follow up assessing any repeat ED visits, satisfaction with their treatment, and the short form Dizziness Handicap Inventory Measure (DHI) was performed (a previously validated tool for measurement of nausea and dizziness on a severity scale.) Differences between the proportions by randomized treatment assignment were compared using a 2-tailed Fisher’s Exact test. Multinomial parameters such as patient satisfaction and the DHI were compared using a Wilcoxon Two-Sample test. Probability values Results: Twenty-six patients were randomized; 11 in the standard treatment arm, and 15 in the interventional arm. The age (mean +/-SD) of subjects randomized to receive maneuver and medication was 59+/-12.6 and 64+/-11.2 respectively; there was no significant difference in age between the 2 treatment arms (p=0.310). Two hours after treatment, the symptoms between the groups showed no difference in the measures of nausea (p=0.548) or dizziness (p=0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9+/-1.5 and 9+/-1.0, respectively; there was no significant difference in satisfaction between the 2 arms (p=0.889). The length of stay during the ED visit did not differ between the treatment groups (p=0.873). None of the patients returned to an ED for similar symptoms. Conclusions: There is no difference in symptomatic resolution and patient satisfaction between standard medical care and canalith repositioning maneuver in this pilot study. Physicians should consider the canalith repositioning maneuver as their standard of care. Considering the potential cost savings, nursing time, and potential for adverse reactions to medications (even the limits on driving due to sedation) and complications from intravenous access, it seems that the maneuver has clear advantages for those so motivated to attempt it

Utilization of the Lempert Maneuver for Benign Paroxysmal Positional Vertigo in the Emergency Department.

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo. Symptoms from BPPV lead to Emergency Department (ED) visits, and persistence of symptoms, particularly in the elderly, may impact patient disposition. We describe the techniques used in the case of a 72-year-old male with dizziness, who had symptom resolution, and was able to be safely discharged after a Lempert maneuver (barbeque (BBQ) roll) was performed in the ED setting. The patient presented to the ED with left gaze nystagmus, and otherwise normal evaluation results. Physical therapy was consulted, and their initial evaluation indicated right horizontal canalithiasis noted by fatiguing right, geotropic nystagmus, but the patient was unable to tolerate further testing due to vomiting. Antiemetic medications were administered and at his follow-up examination an hour later, a total of three Lempert maneuvers were performed, resulting in total symptom resolution. Successful utilization of the Lempert maneuver to treat BPPV can help to reduce ED length of stay and increase patient satisfaction. Because of this, the Lempert maneuver should be considered a fast, cost-effective, and safe method of alleviating BPPV symptoms

A customized early warning score enhanced emergency department patient flow process and clinical outcomes in a COVID-19 pandemic.

Objective: Patient crowding and boarding in the emergency department (ED) is associated with adverse outcomes and has become increasingly problematic in recent years. We investigated the impact of an ED patient flow countermeasure using an early warning score. Methods: We conducted a cross-sectional analysis of observational data from patients who presented to the ED of a Level 1 Trauma Center in Pennsylvania. We implemented a modified version of the Modified Early Warning Score (MEWS), called mMEWS, to address patient flow. Patients aged ≥18 years old admitted to the adult hospital medicine service were included in the study. We compared the pre-mMEWS (February 19, 2017-February 18, 2019) to the post-mMEWS implementation period (February 19, 2019-June 30, 2020). During the intervention, low MEWS (0-1) scoring admissions went directly to the inpatient floor with expedited orders, the remainder waited in the ED until the hospital medicine admitting team evaluated the patient and then placed orders. We investigated the association between mMEWS, ED length of stay (LOS), and 24-hour rapid response team (24 hour-RRT) activation. RRT activation rates were used as a measure of adverse outcome for the new process and are a network team response for admitted patients who are rapidly decompensating. The association between mMEWS and the outcomes of ED length of stay in minutes and 24 hour-RRT activation was assessed using linear and logistic regression adjusting for a priori selected confounders, respectively. Results: Of the total 43,892 patients admitted, 19,962 (45.5%) were in the pre-mMEWS and 23,930 (54.5%) in the post-mMEWS implementation period. The median post-mMEWS ED LOS was shorter than the pre-mMEWS (376 vs 415 minutes; Conclusion: The use of a modified MEWS enhanced admission process to the hospital medicine service, even during the COVID-19 pandemic, was associated with a significant decrease in ED LOS without a significant increase in 24 hour-RRT activation

Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay

Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay Richard S. MacKenzie, MD, David B. Burmeister, DO, Jennifer A. Brown, RN, Melissa Teitsworth, RN, BSN, Christopher J. Kita, MEd, Megan J. Dambach, DO, Shaheen Shamji, DO, Anita Kurt, PhD, RN , Susan Friend, Marna Greenberg, DO, MPH Acknowledge: Clare M. Lenhart, PhD, MPH Objective: Emergency Department (ED) crowding is an on-going formidable issue for many EDs. A Rapid Assessment Unit (RAU) is a potential solution. This process involves the use of a team approach to convert the current “series” type evaluation to a more “parallel” evaluation and treatment of patients. The RAU concept of evaluating and treating ED patients radically changes the current methods utilized in today’s standard emergency care area. The RAU concept offers a process in which the patient walks into the ED and is seen in a unit by an intake team composed of a nurse, registrar, and provider (physician assistant, nurse practitioner, or physician) that provides evaluation and emergent treatment. This removes the redundancy of a patient giving the same information several times before they are treated. Simultaneously, the team decides whether the patient would be better served by remaining seated or requires a recumbent position. This is referred to as allowing “vertical flow” versus the default “horizontal flow” where all patients recline on a stretcher whether they need it or not. Certainly, having construction that specifically supports these processes is an innovation as well (having an area where patients can be seated and remain “vertical”). The team structure itself is unique. The nurses and providers are not assigned geographically by room but rather are defined by their function. We set out to determine if the addition of the RAU process would decreases the LOS of the discharged ambulatory arrival patient. Methods: After IRB approval, this retrospective, pre- and post intervention, observational comparison study was conducted from August 2011-March 2012 at a suburban teaching hospital in central Pennsylvania with an annual ED census of approximately 54,000. The inclusion criteria were all ambulatory discharged patients. The exclusion criteria were all patients that arrived by ambulance and admitted patients. Data points captured included: time of arrival in triage , time in triage to ED entry, time of ED entry until seen by a provider, time from ED entry to discharge, total length of stay (LOS). The data were uploaded to Horizon Business Insight™ (HBI), a cumulative data manager and exported to an Microsoft excel file for analysis. Mann-Whitney U tests were used to demonstrate differences in Median LOS. All statistical tests were 2-sided; probability values \u3c0.05 were considered significant. Results: 11, 994 pre and 10814 post-RAU patients were included in analysis. Median LOS was shorter during the post-RAU period in each subcategory of LOS with the exception of the interval from being seen in the ER to discharge which is a result of provider seeing the patient earlier in the ED encounter. Results, Table 1. Conclusions: The RAU process decreases the LOS of the discharged ambulatory arrival patient and deserves further exploration as an innovative model in the ED that improves flow