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Factors influencing HINTS exam usage by Canadian Emergency Medicine Physicians

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Abstract

Objectives

The HINTS examination (head impulse, nystagmus, test of skew) is a bedside physical examination technique that can distinguish between vertigo due to stroke, and more benign peripheral vestibulopathies. Uptake of this examination is low among Emergency Medicine (EM) physicians; therefore, we surveyed Canadian EM physicians to determine when the HINTS exam is employed, and what factors account for its low uptake.

Methods

We designed and tested a 26-question online survey, and disseminated it via email to EM physicians registered with the Canadian Association of Emergency Physicians (CAEP), with 3 and 5-week reminder emails to increase completion. This anonymous survey had no incentives for participation, and was completed by 185 EM physicians, with post-graduate medical training in either Emergency Medicine or Family Medicine. The primary outcomes were the frequencies of various responses to survey questions, with secondary outcomes being the associations between participant characteristics and given responses.

Results

88 respondents (47.8%) consistently use the HINTS examination in the work-up of vertigo, and 117 (63.7%) employ it in scenarios where its clinical utility is limited. The latter is more common among physicians working in non-academic settings, without 5-year EM residency training, and with greater years of practice (p < 0.01). The most frequent explanations for non-use were a lack of need for the HINTS examination, the lack of validation of the exam among EM physicians, and concerns surrounding the head-impulse test.

Conclusions

Though HINTS exam usage is common, there is a need for education on when to apply it, and how to do so, particularly as concerns the head-impulse test. Our attached rubric may assist with this, but quality-improvement initiatives are warranted. Low uptake is partly due to the lack of validation of this examination among EM physicians, so effort should be made to conduct well-designed HINTS trials exclusively involving EM physicians.

Résumé

Objectifs

L'examen HINTS (head impulse, nystagmus, test of skew) est une technique d'examen physique au chevet du patient qui permet de distinguer les vertiges dus à un accident vasculaire cérébral des vestibulopathies périphériques plus bénignes. Cet examen est peu pratiqué par les médecins en médecine d’urgence (MU). Nous avons donc mené une enquête auprès des médecins d'urgence canadiens afin de déterminer quand l'examen HINTS est utilisé et quels sont les facteurs qui expliquent sa faible utilisation.

Méthodes

Nous avons conçu et testé une enquête en ligne de 26 questions, et l'avons diffusée par courriel aux médecins urgentistes inscrits à l'Association canadienne des médecins d'urgence (ACMU), avec des courriels de rappel de trois et cinq semaines pour augmenter le taux de réponse. Cette enquête anonyme, qui ne comportait aucune incitation à la participation, a été remplie par 185 médecins de médecine d'urgence ayant suivi une formation médicale postuniversitaire en médecine d'urgence ou en médecine familiale. Les résultats primaires étaient les fréquences des diverses réponses aux questions de l'enquête, les résultats secondaires étant les associations entre les caractéristiques des participants et les réponses données.

Résultats

88 répondants (47,8 %) utilisent systématiquement l'examen HINTS dans l'évaluation des vertiges, et 117 (63,7 %) l'emploient dans des scénarios où son utilité clinique est limitée. Cette dernière est plus fréquente chez les médecins travaillant dans des établissements non universitaires, n'ayant pas suivi une formation de 5 ans en résidence en médecine d'urgence et ayant un plus grand nombre d'années de pratique (p < 0,01). Les explications les plus fréquentes de la non-utilisation étaient le manque de nécessité de l'examen HINTS, le manque de validation de l'examen parmi les médecins de médecine d'urgence et les préoccupations concernant le test d'impulsion de la tête.

Conclusions

Bien que l'utilisation de l'examen HINTS soit courante, il existe un besoin d'éducation sur le moment où il faut l'appliquer et sur la manière de le faire, en particulier en ce qui concerne le test d'impulsion de la tête. Notre rubrique ci-jointe peut vous aider à cet égard, mais des initiatives d’amélioration de la qualité sont justifiées. Le faible taux d'utilisation est en partie dû au manque de validation de cet examen parmi les médecins de la médecine d'urgence. Il faut donc s'efforcer de mener des essais HINTS bien conçus impliquant exclusivement des médecins de la médecine d'urgence.

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Author information

Authors and Affiliations

  1. Department of Medicine, Division of Neurology, McMaster University, Hamilton, ON, Canada

    Miles Byworth

  2. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    Peter Johns

  3. Division of Emergency Medicine, Department of Medicine and Pediatrics, McMaster University, Hamilton, ON, Canada

    Alim Pardhan

  4. Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Kavita Srivastava

  5. Department of Medicine, McMaster University, and Population Health Research Institute, Hamilton, ON, Canada

    Mike Sharma

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  1. Miles Byworth
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Correspondence to Miles Byworth.

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Byworth, M., Johns, P., Pardhan, A. et al. Factors influencing HINTS exam usage by Canadian Emergency Medicine Physicians. Can J Emerg Med 24, 710–718 (2022). https://doi.org/10.1007/s43678-022-00365-2

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