Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support?

Abstract

Objectives: Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts.

Methods: Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population-based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made.

Results: Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis.

Conclusions: Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations.

Figure 1

Examples of common peripheral, central, and physiological patterns of nystagmus

Figure 2

Results of the assessment about agreement with the statement: “The recorded nystagmus description enabled a meaningful inference about the localization or the cause of the nystagmus.” Population = visits with documentation of presence of nystagmus (n = 185). Examples of strongly disagree: no description provided, “positive,” “with raising up out of bed.” Examples of somewhat disagree: “to left,” “rapid,” “lateral,” “mild,” “horizontal,” “nystagmus bilateral,” “fatigable.” Examples of somewhat agree: “few beats,” “1-2 beats of horizontal nystagmus,” “scant with right gaze,” “bilateral lateral, fatigues quickly.” Example of strongly agree: “marked bilateral.”