Abstract TP231: Combining the VAIN Triad with the HINTS exam Optimizes Detection of Posterior Circulation Strokes in the ED

Introduction: Acute posterior circulation (PC) stroke is one of the most dangerous central causes of vertigo that requires urgent intervention. Two tools to triage vertigo are often underutilized in the ED setting: the Head-Impulse, Nystagmus, Test-of-Skew (HINTS) exam, which has been shown to be more sensitive than MRI with DWI in detecting acute stroke in the first 24 to 48 hours after symptom onset; and the Vertigo-ataxia, incessant, non-positional (VAIN) triad, which has been shown to offer 100% sensitivity in detecting central vertigo. At our ED, both clinical criteria are often underreported in the preliminary work up prior to the placement of a formal neurology consult. We conducted a systems-based quality improvement project to formalize a pathway for vertigo evaluation that optimizes detection of PC strokes in our ED and reduces the number of consults placed to Neurology without an appropriate preliminary workup. Methods: This study was conducted at Jack D. Weiler Hospital ED of Montefiore Medical Center in Bronx, NY. A root cause analysis was conducted to identify barriers to performing a comprehensive preliminary evaluation. Patients presenting with a chief complaint of dizziness from March 1, 2024 – December 31, 2024 were retrospectively reviewed for metrics inclusion. The data was organized into a Pareto chart (Figure 1). Resident-designed educational materials (Figure 2&3) were implemented as clinical triage tools via physical and online formats. Results: A total of 34 patients were included in the pre-implementation analysis. Of those patients, 0% of charts reviewed documented the HINTS exam. The VAIN triad was included at higher rates – ataxia (30%), incessant (41%), non-positional dizziness (18%). An MRI Brain was obtained in about 56% of cases. Overall, about 9% of patients had a PC stroke. In those who had an MRI, about 11% of patients had a confirmed PC stroke. Conclusions: The HINTS exam and VAIN clinical criteria are significantly underutilized in our ED, creating an opportunity to optimize the triage pathway for patients presenting with dizziness. A notable proportion of patients in our small sample who had PC strokes confirmed on MRI further emphasizes the need for an effective triage pathway that streamlines vertigo assessment and mitigates the risk of untimely detection of PC strokes in our population.