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Developing an implementation intervention for managing acute vertigo in the emergency department
  1. David Herdman1,
  2. Hena Ahmad2,
  3. George Antoniades3,
  4. Gokul Bailur3,
  5. Arun Pajaniappane1,
  6. Phil Moss3
  1. 1 Audiovestibular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
  2. 2 Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
  3. 3 Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to Dr David Herdman, Audiovestibular Medicine, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK; David.Herdman{at}


Background There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science.

Methods A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests. The survey was sent to emergency clinicians (ECs) in a teaching hospital in London, UK, between May and September 2022. Semistructured interviews were conducted simultaneously, and data examined using direct content analysis. Implementation strategies were then selected based on the Expert Recommendations for Implementing Change framework.

Results Fifty-one ECs responded to the survey and six ECs volunteered for interview. Less than half reported using the bedside tests to make a diagnosis. The most common barriers were beliefs about complexity, a lack of supporting materials, memory, lack of skills and negative experiences. The interview data revealed negative beliefs about the necessity, validity, safety and practicality. There were also barriers in the ED environment (eg, lack of space). There was a strong perception that the current approach to managing acute vertigo needed to change and ECs view this as part of their professional role and responsibility. Based on clinician input, the authors selected strategies to improve diagnostic efforts, which included guidelines for training, developing vertigo champions, protocols, memory aids, audit and feedback.

Conclusion This study found several barriers to managing acute vertigo such as memory constraints, and inadequate supporting materials and training, although a robust desire for change. The implementation strategy’s initial phase is described, which must now be tested.

  • stroke
  • Diagnostic Tests
  • ENT

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Handling editor Aileen McCabe

  • Twitter @DHerdmanPT

  • Contributors DH—guarantor, conceptualisation, data curation, formal analysis, methodology, writing (original draft), writing (review and editing). HA—formal analysis, methodology, writing (review and editing). GA—data curation, methodology. GB—data curation, methodology. PM—data curation, formal analysis, methodology, writing (review and editing). AP—formal analysis, methodology, writing (review and editing).

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.