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SETTING THE STANDARDS: AUDITING MANAGEMENT OF FIRST SEIZURE IN THE EMERGENCY DEPARTMENT OF A UK TEACHING CENTRE
  1. Sophie Binks,
  2. Maria Finn,
  3. Julia Aram
  1. Brighton and Sussex Medical School; Brighton and Sussex University Hospitals NHS Trust

    Abstract

    Background Seizure is a common neurological problem. The College of Emergency Medicine (CEM) estimates it underpins 1.2% of emergency department (ED) attendances, of which a quarter may be first seizure.1 Rates of drug and alcohol use are higher in Brighton than the rest of the country.2 These triggers may represent additional reasons for presentation with seizure to Brighton and Sussex University Hospitals NHS Trust (BSUH).

    The recent launch of the National Audit of Seizure Management in Hospitals (NASH) has focused attention on management of seizure, including first seizure.3 Our project set out to compare emergency management of first seizure patients in the ED of BSUH to national standards. It also aimed to evaluate the impact of a previous first seizure audit in 2011 and the initiation of a first seizure clinic, intended to streamline the referral process.

    Patients and methods Cases were identified from referrals to a first seizure clinic from March 2011–May 2012. Of 83 eligible cases, 62 were retrieved by medical records and retrospectively reviewed. Two inappropriate referrals were excluded. The remaining 60 were analysed against selected standards drawn from: CEM–Guideline for Management of First Seizure in the ED (2009);1 International League against Epilepsy–Adult First Seizure Assessment Audit Proforma (2011);4 NASH study group–National Audit of Seizure Management in Hospitals (2012);3 NICE–clinical guideline 137 (updated 2012);5 and DVLA driving guidance.6

    Results The median age of BSUH first seizure patients was younger than the NASH national seizure cohort (33.5 vs. 44 years) and more were male (63% vs. 57%). There were higher rates of excess alcohol intake (49% vs. 43.6% where documented) and illicit drug use (62.5% vs. 32.7% positive where documented) compared to NASH first seizure patients. Comparison of appropriate parameters identified by NASH as potential ‘key quality indicators’ revealed temperature recorded in 90% of cases (NASH 86.9%); evidence of first–hand eyewitness account in 58% (NASH 62.5%); plantars performed in 17% (NASH first seizure group 47.2%); ECG in 72% (NASH first seizure group 71.7%); and evidence of a discussion around driving in 77% (NASH first seizure group 26.2%). As stipulated by CEM guidelines, serum sodium was achieved in 98%, BM/serum glucose in 83% (NASH first seizure group 74.1%) and βHCG in women of child–bearing potential in 32%. Since instigating the first seizure clinic, the proportion of BSUH patients receiving head CT in the ED has decreased from 83% to 47% with all scans meeting CEM advice. 25% of patients did not attend their outpatient neurology appointment. Most (93%) non–attenders were male with a median age of 26.

    Conclusions This audit identified areas of good practice and some for improvement. Many aspects of the neurological examination were well documented, but plantars were rarely performed. The first seizure proforma has subsequently been amended to include ‘prompts’ of key actions for clerking doctors and its effect will be assessed by re–audit. Young men were at high risk of missing their follow–up appointment and may represent a target group for investigations and advice within the ED.

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