DIZZiness Treatment through ImplementatioN & Clinical strategy Tactics (DIZZTINCT-2) Project

项目总结/摘要 头晕在急诊科（艾德）是一个常见的问题，有许多机会实施 有效和基于证据的做法。在DIZZTINCT-1中，我们开发并评估了一个实现 一项战略，重点是提高Dix-Hallpike测试（DHT）的性能和canalith重新定位 在艾德中，通过应用以良性阵发性位置性眩晕（BPPV）为中心的方法，我们 发现该策略大大提高了DHT和CRM的性能。在实现保真度 在访谈中，开始使用DHT和CRM的供应商通常报告了积极的体验，如 他立刻感觉好多了，大约20分钟后就走了出去......太棒了。 头部CT的使用也有所减少，这通常是不必要的BPPV为中心的 approach.重要的是，头部CT的减少并没有导致卒中误诊的增加。 然而，DIZZTINCT-1的扩大潜力有限，因为它使用了研究者主导的教育 会议，现金奖励，并没有在非学术设施充分参与。我们学到 关于战略的重要修订，可以增加普遍性和更多的常规提供者使用， 尤其是在非学术性的ED中。在DIZZTINCT-2中，我们将从四个方面加强和完善该战略。第一、 由于我们将利用当地提供者和在线继续医学教育， 程序.第二，我们将扩大目标提供者，包括护士，因为我们了解到，护士可以发挥 在实施以BPPV为中心的方法方面发挥重要作用。第三，我们将响应供应商的请求， 该主题包括在头晕就诊和循证诊断中评估中风风险的最佳实践， 前庭神经炎的治疗扩大这一主题既可以增加对以BPPV为中心的 资源，并为最佳做法创造更多机会。第四，我们将增加以病人为导向的资源， 这也响应了供应商的要求，并增加了最佳管理的机会。对于DIZZTINCT- 2，我们已经与凯撒永久南加州（KPSC）合作，测试这一战略。KPSC有12个 ED和每年约40，000次头晕访视。DIZZTINCT-2将使用混合型3实施有效性 艾德实施策略的阶梯式楔形随机试验和嵌入式随机试验 患者层面的传播策略。我们有以下具体目标：目标1。为了确定 修订并增强了以BPPV为中心的实施策略，以改善DHT/CRM在头晕访视中的表现， 在学术和非学术ED，使用随机阶梯楔形设计。目标2.评价临床 与实施战略相关的成果，同时使用阶梯式楔形ED级战略和 患者水平传播策略的嵌入式随机临床试验。DIZZTINCT-2是第一项研究， 应用并评估一项广泛的策略，以加强头晕就诊的最佳护理，重点关注非学术性ED， 并测量实施和患者结果。

Project Summary/ Abstract Dizziness in the emergency department (ED) is a common problem with many opportunities to implement efficient and evidenced-based practices. In DIZZTINCT-1, we developed and evaluated an implementation strategy that focused on increasing the performance of the Dix-Hallpike test (DHT) and canalith repositioning maneuver (CRM) in the ED by applying a benign paroxysmal positional vertigo (BPPV) -centric approach. We found that the strategy substantially increased DHT and CRM performance. In implementation fidelity interviews, providers who started using the DHT and CRM typically reported positive experiences, as reflect by the following quote: “He immediately felt better and walked out about 20 minutes later…it was awesome.” There was also a decrease in the use of head CTs, which are typically unnecessary with a BPPV-centric approach. Importantly, the decrease in head CTs did not lead to an increase in stroke misdiagnosis. DIZZTINCT-1, however, is limited in its potential to scale-up because it used investigator led education sessions, cash incentives, and did not have adequate engagement at nonacademic facilities. We learned about important revisions to the strategy that could increase generalizability and more routine provider use, particularly at nonacademic EDs. In DIZZTINCT-2, we will enhance and refine the strategy in four ways. First, the education sessions will be more generalizable because we will utilize local providers and an online CME program. Second, we will broaden the target providers to include nurses since we learned that nurses can play a major role in implementing the BPPV-centric approach. Third, we will respond to provider requests to expand the topic to include best practices for assessing stroke risk in dizziness visits and evidence-based diagnosis & management for vestibular neuritis. Expanding the topic could both increase exposures to the BPPV-centric resources and create more opportunities for best practices. Fourth, we will add patient-oriented resources, which also responds to providers’ requests and increases opportunities for best management. For DIZZTINCT- 2, we have partnered with Kaiser Permanente Southern California (KPSC) to test the strategy. KPSC has 12 EDs and ~40,000 annual dizziness visits. DIZZTINCT-2 will use a hybrid type 3 implementation-effectiveness trial of a stepped wedge randomized trial for the ED implementation strategy and an embedded randomized patient-level dissemination strategy. We have the following specific aims: Aim 1. To determine the impact of the revised and enhanced BPPV-centric implementation strategy on DHT/CRM performance in dizziness visits, at academic and nonacademic EDs, using a randomized stepped wedge design. Aim 2. To evaluate clinical outcomes associated with the implementation strategy using both a stepped wedge ED-level strategy and an embedded randomized clinical trial of a patient-level dissemination strategy. DIZZTINCT-2 is the first study to apply and evaluate a broad strategy to enhance optimal care in dizziness visits, to focus on nonacademic EDs, and to measure both implementation and patient outcomes.