A Novel Tele-Dizzy Consultation Program in the Emergency Department Using Portable Video-Oculography to Improve Peripheral Vestibular and Stroke Diagnosis (S28.002)

Objective: We sought to deploy a tele-dizzy consultation service to improve diagnosis of acute dizziness and vertigo in the ED. Background: 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. Design/Methods: 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. Results: 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. Conclusions: 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. Disclosure: Dr. Gold has nothing to disclose. Dr. Tourkevich has nothing to disclose. Dr. Shemesh has nothing to disclose. Dr. Brune has nothing to disclose. Dr. Choi has nothing to disclose. Dr. Peterson has nothing to disclose. Dr. Bosely has nothing to disclose. Dr. Maliszewski has nothing to disclose. Dr. Fanai has nothing to disclose. Dr. Otero-Millan has nothing to disclose. Dr. Roberts has nothing to disclose. Dr. Zee has nothing to disclose. Dr. Newman-Toker has nothing to disclose.