Improper performance of HINTS exam in emergency physicians is driven by incorrect use of nystagmus

Objective: The HINTS exam is a useful clinical tool for the emergency physician (EP) to differentiate between a central or peripheral cause of dizziness in patients with continuous dizziness and nystagmus and GRACE guidelines strongly recommend that EPs utilize this test. However, previous data show variable results on how well EPs perform the HINTS exam. We aimed to retrospectively assess how accurately EPs select patients for (and thus correctly perform) the HINTS exam. Methods: A retrospective study was conducted using one full year of patient charts from the emergency department of a public hospital with an emergency residency program. Charts were pulled from the EMR if they contained the words: “hints,” “skew,” or “impulse.” Charts were then manually reviewed and irrelevant charts were excluded. Remaining charts were analyzed for documentation and interpretation of the HINTS exam and categorized as “appropriate” vs “inappropriate” vs. “either way”. “Inappropriate” charts were analyzed further for presence of nystagmus and dizziness. Results: A total of 175 patient encounters were reviewed in this study, of which 29 cases were inapplicable. Of the remaining 146 cases, 71.2 % (95 % CI 63.5–78.1 %) of HINTS exams were performed on inappropriate patients. The majority of these was due to the exam's being performed on patients without nystagmus. Conclusions: Based on our findings, EPs utilize the HINTS exam inappropriately the vast majority of the time. Much of this is due to their performing the HINTS exam on patients without nystagmus.