Documentation of Nystagmus Assessment in Acute Vertigo: A Retrospective Audit of Emergency Department Practice and Variability in Two Regional Australian Hospitals

Abstract

Vertigo is a common emergency department (ED) presentation. Assessment can be challenging due to various etiology and subtle clinical signs. Nystagmus is an important clinical feature, yet documentation of its key descriptors is often incomplete. This study aimed to evaluate the documentation of nystagmus characteristics in patients presenting with acute vertigo to two regional EDs. Secondary objectives included examining neuroimaging utilization and the relationship between nystagmus and HINTS (+) testing (Head Impulse, Nystagmus, and Test of Skew plus the addition of sensorineural hearing loss and truncal ataxia). Retrospective observational audit of electronic medical records from two EDs within the Central Coast Local Health District, New South Wales, Australia. Patients presenting with acute dizziness (n = 1942) from January-December 2023 who reported vertigo (n = 325) were included. Documentation of nystagmus and its characteristics, HINTS (+) competition, and neuroimaging utilization were analyzed and compared between sites. Nystagmus was documented in 89 cases, with direction reported in 97% (n = 86), duration 22% (n = 20), and magnitude in 13% (n = 12). Assessment with fixation removed was not performed. Neuroimaging was conducted in 47% (n = 152) of all vertigo presentations; with computed tomography angiogram used in 32% (n = 105), showing a diagnostic yield of 2%. HINTS (+) was documented in 25% (n = 80) of vertigo presentations, of which 60% (n = 48) were performed despite absent or undocumented spontaneous nystagmus. Nystagmus assessments are frequently performed in the ED, but detailed descriptors are inconsistently recorded. Neuroimaging utilization remained high despite low diagnostic yield. HINTS (+) examinations were frequently performed in patients that had no documented spontaneous nystagmus. These findings identified clear practice gaps, highlighting the need for targeted training in nystagmus assessment.