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

项目摘要/摘要 急诊科(ED)的头晕是一个常见的问题，有很多机会实施 有效和以证据为基础的做法。在DIZZTINCT-1中，我们开发并评估了一个实现 专注于提高Dix-Hallpike测试(DHT)和管石重新定位的性能的战略 以良性阵发性位置性眩晕(BPPV)为中心的手法在ED中的应用。我们 研究发现，该策略显著提高了分布式哈希表和客户关系管理的绩效。在实施保真度方面 在采访中，开始使用DHT和CRM的提供商通常报告了积极的体验，这反映在 下面引用他的话：“他立刻感觉好多了，大约20分钟后，他离开了…。真是太棒了。 头部CT的使用也减少了，这对于以BPPV为中心的患者来说通常是不必要的 接近。重要的是，头部CT的减少并没有导致中风误诊的增加。 然而，DIZZTINCT-1在扩大规模方面的潜力有限，因为它使用了调查人员领导的教育 课程、现金奖励，以及在非学术设施中没有足够的参与度。我们了解到 关于对战略的重要修订，这些修订可以增加普适性和更常规的提供者使用， 尤其是在非学术性的EDS中。在DIZZTINCT-2中，我们将从四个方面加强和细化战略。第一, 教育课程将更具普遍性，因为我们将利用当地供应商和在线CME 程序。其次，我们将扩大目标提供者的范围，将护士包括在内，因为我们了解到护士可以 在实施以业务伙伴关系为中心的办法方面发挥重要作用。第三，我们将响应提供商的扩展请求 本主题将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。扩大话题既可能增加对以BPPV为中心的风险敞口 资源，并为最佳做法创造更多机会。四是增加以患者为中心的资源， 它还响应提供商的请求，并增加最佳管理的机会。对于DIZZTINCT- 2，我们已经与南加州凯撒永久酒店(KPSC)合作测试这一战略。KPSC有12个 EDS和每年约40,000次头晕访问。DIZZTINCT-2将使用混合类型3实施-有效性 ED实施策略的阶梯楔形随机试验和嵌入随机试验 患者层面的传播策略。我们有以下具体目标：目标1.确定 修订和加强了以BPPV为中心的实施战略，以改善DHT/CRM在头晕就诊中的表现， 在学术和非学术EDS中，使用随机阶梯楔形设计。目的2.评估临床 与使用阶梯式楔形教育级别战略和 嵌入患者水平传播策略的随机临床试验。DIZZTINCT-2是第一个研究 应用和评估广泛的战略，以加强头晕就诊的最佳护理，专注于非学术性急救， 并衡量实施情况和患者结果。

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.