The Johns Hopkins University School of Medicine

Virtual Patient Education from Real Cases (ViPER) to Improve ED Diagnosis of Dizziness and Stroke

Project Lead: Susrutha Kotwal, MD

Project AIM(s): Using a combination of virtual patient training and direct performance feedback for ED residents, within 1 year we will:

  1. Reduce by 50% the rate of ED residents’ diagnostic process failures in dizziness charts
  2. Increase ED residents’ diagnostic accuracy for dizziness by 20% (absolute gain)
  3. Reduce by 25% the rate of inappropriate computed tomography (CT) scans for dizzy patients seen by residents

Narrative Description

The Principal Investigator (PI) created a VP curriculum (ViPER) for internal medicine residents at the Johns Hopkins Bayview Medical Center using real patient data derived from an ongoing, NIH-sponsored, multi-center, Phase II clinical trial (AVERT) that digitally records clinical findings in ED patients with dizziness. Pilot data showed that less than 10 hours of exposure to ViPER was able to significantly improve the bedside clinical reasoning of novice clinicians (interns) compared to graduating residents (diagnostic accuracy 50% vs. 20%, p=0.001; imaging appropriateness 65% vs. 25%, p<0.001).

The PI created the VP library of 24 dizzy patients using the VIC (Virtual Interactive Case) software. Learners obtain a history, conduct a physical exam, and make diagnostic and therapeutic decisions (clinical reasoning). The software provides detailed, individualized feedback to learners using the principles of deliberate practice. Cases include both benign, common causes (e.g., benign paroxysmal positional vertigo, vestibular neuritis) and less
common, dangerous causes (e.g., stroke) of dizziness.

For the current QI intervention, via multiple PDSA cycles, ViPER was combined with direct performance feedback to residents obtained through chart reviews (e.g., documentation of correct bedside techniques). As part of the PDSA process, feedback about the ViPER curriculum itself was incorporated to iteratively improve both the curriculum and the mechanism for performance feedback to residents. The combination of deliberate practice and direct, systematic feedback on diagnostic performance is intended to create mutually reinforcing improvement in practice.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)