Written by Nickolas Srica, MD
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In ED patients with vertigo, the STANDING algorithm had high diagnostic accuracy and negative predictive value for central causes while reducing CT imaging and length of stay compared to “usual care.” But the main caveat here was that these emergency physicians underwent dedicated training in the algorithm.
STANDING on business…
This was a prospective, multicenter observational study done across four EDs in the Tuscany region of Italy, which included one major teaching hospital and three community hospitals. Each site had at least 3 emergency physicians who received dedicated training in the STANDING algorithm. 456 patients were analyzed, with 242 (53%) being assessed using the STANDING algorithm and 214 (47%) being assessed via “usual care” (a.k.a. no trained EP available, so no standardized approach). The STANDING group achieved a sensitivity of 88.2%, specificity 91.6%, NPV 99%, and PPV 44% for central causes, while the usual care group had sensitivity 95.5%, but specificity of only 36.5% (p<0.01), with a lower PPV of 15% (p=0.001). Patients evaluated with STANDING also underwent fewer non-contrasted head CTs (48.3% vs 66.8%, p<0.01) and had a shorter ED LOS (median 271 vs 339 minutes, p<0.05). Neither group’s “benign” patients after assessment had any deaths, strokes, or instances of reperfusion or neurosurgical intervention on follow up.
How does this change my practice?
“Dizziness” is tough. There’s a reason many of us dread seeing this chief complaint pop up on shift. There have been a number of recent studies that show promising results for approaches like the HINTS exam or the STANDING algorithm, but there have also been prior studies showing that perhaps we’re not as good at these as we think. The key is that many of the more promising studies included dedicated training in these exam techniques before applying them. For those of us in academics, these should be a bigger part of the curriculum. For those not in academics, training for your group might help. In the meantime, getting that occasional specialist consultation or MRI shouldn’t be viewed as a loss… this isn’t easy!
*Author’s note: some of the prior articles hyperlinked above include great tips and reminders for both the HINTS exam and the STANDING algorithm. Take a peek for a refresher!
Source
Diagnostic Accuracy of the STANDING Algorithm in Patients with Isolated Vertigo: A Multicentre Prospective Study (STANDING-M). Emerg Med J. 2025 Jul 29. doi: 10.1136/emermed-2025-214902. PMID: 40730460.
