Integrated Care Pathway
Management of adult and paediatric patients presenting to the Emergency Department with a suspected first seizure
April 2012
Inclusion Criteria
This pathway is designed to assist medical and nursing professionals in the management of patients who present to the emergency department with a suspected first seizure. The plan is to pilot the pathway in the Swansea area in 2012. The pathway should be used for both adults and children who fulfill the following criteria;
· Episode of transient loss of consciousness, suspected seizure
· No previous diagnosis of epilepsy
· Not receiving anti-epileptic medication
This pathway evidence based but not rigid. Clinicians may use their professional judgment and document reasons for doing so.
Background
Epilepsy is the most common serious neurological condition, with 1500 new cases per year in Wales, and 20-30,000 with active disease. It is responsible for a high proportion of unscheduled hospital admissions and has been identified as one of the most common causes of unplanned admissions across Wales (1), resulting in a significant NHS burden in terms of both cost and resources.
The early and accurate diagnosis of suspected epilepsy is key to preventing unscheduled admissions. Making the correct diagnosis can be challenging and studies have revealed misdiagnosis rates of up to 30% (2). This leads to inappropriate investigations and treatment, poor seizure control and unnecessary and preventable hospital admissions. Achieving prompt diagnosis is one of the key recommendations of the national service framework for long term conditions (3) and the NICE guidelines suggest that all individuals with a recent suspected seizure should be seen by a specialist within 2 weeks of onset (4).
The establishment of rapid access clinics in each health board for the assessment of patients presenting to primary care and the emergency department (ED) with suspected seizures was identified as one of the first set of High Impact Changes in the management of patients with chronic diseases (1). The aim is to ensure prompt and accurate diagnosis and to establish individual management plans with appropriate treatment strategies that meet the needs of patients. The current waiting times for outpatient appointments make the existing epilepsy clinics unsuitable for dealing with these patients.
The ‘development of alternative pathways for short stay emergency conditions’ is listed as one of the unscheduled care priorities in ‘Changing for the better’, the health board’s strategy and priorities for the next 5 years (5). This pathway is designed to coordinate care across multi-disciplinary services for patients presenting to the ED with suspected seizures and has clear outcome measures for auditing and monitoring. It is the first step in the development of a comprehensive epilepsy pathway that will allow patients to be managed in the community and support patient self-care and independence.
Suspected first seizure pathway - Adults
Pathway Notes - Adults
1-2. A detailed clinical assessment should be undertaken to identify the likely cause of loss of consciousness, including a witness description where possible. The management of patients experiencing a seizure may be commenced prior to arrival in the ED and it is important to be aware of any pre-hospital treatment given. The ED has protocols for the management of patients requiring emergency treatment to terminate seizures.
3. Guidelines exist within the ED to aid the decision as to whether the patient is discharged home or referred to the medical team for further clinical management. In general patients can be discharged if
· Fully recovered
· No focal neurological deficit
· Initial investigations normal
· Patient is provided with all relevant verbal and written health & safety information relating to possible diagnosis of seizure, including driving advice.
4. The patient is discharged and referred to the fast track seizure clinic receiving an appointment for review by the neurology consultant. The aim is that patients will be reviewed within 2 weeks. The referral request should be sent electronically to . In all instances the patient’s GP is informed of the management plan.
5. Patients presenting to their GPs following a suspected first seizure can also be referred directly to the fast track seizure clinic.
6. Patients with suspected cardiac syncope require urgent cardiology review and will be discussed in the transient loss of consciousness (TLOC) MDT.
7-8. Patient requires admission to the Medical Admission Unit for further investigation and management. Clinical guidelines for the management of seizures are initiated if necessary. (See appendix)
Consider inpatient neurology review if
• Ongoing seizure activity
• Additional neurological features
• Underlying diagnosis unclear after initial investigations
Suspected first seizure pathway – Children
→
Pathway Notes – Children
1-2. A detailed clinical assessment should be undertaken to identify the likely cause of loss of consciousness, including a witness description where possible. The management of patients experiencing a seizure may be commenced prior to arrival in the ED and it is important to be aware of any pre-hospital treatment given. The ED has protocols for the management of patients requiring emergency treatment to terminate seizures.
3. The majority of children can be discharged following a seizure. The indications for admission/referral to PAU are;
· Age less than 1 year
· Any of the following features on examination
o GCS (or equivalent) <15 one hour after seizure
o New neurological signs
o Raised intracranial pressure – papilloedema, tense fontanelle
o Signs of meningism
· Complex seizure
o Duration > 15 minutes
o Seizures in preceding 24 hours
· Signs of aspiration
No investigations are needed routinely.
4. The patient is discharged and referred to the fast track seizure clinic receiving an appointment for review by the Children’s Epilepsy Service. The aim is that patients will be reviewed within 2 weeks. Referrals are accepted from the ED and primary care. The referral request should be sent electronically to the neurologists electronically to . In all instances the patient’s GP should be informed of the management plan.
5. Patients presenting to their GPs following a suspected first seizure can also be referred directly to the fast track seizure clinic.
References
1. High Impact Service Changes. Delivering high quality, cost-effective care in the community.
2. Designed for people with Chronic Conditions. Welsh Assembly Government Service Development Directive for Epilepsy. January 2009
3. The National Service Framework for Long-term Conditions. Department of Health, March 2005.
4. The Epilepsies - the diagnosis and management of the epilepsies in adults and children in primary and secondary care. NICE guideline, October 2004.
5. Changing for the better. Our five year plan. ABM health board, August 2010.
Appendix 1: Adult rapid access seizure clinic- ED referral form
Criteria for referral:
· Episode of transient loss of consciousness, suspected seizure
· Does not require hospital admission
· The patient is 16 years or older
· No previous diagnosis of epilepsy or prescribed anti-epilepsy medication
Name: ………………………………M/F Address: …………………………..
DOB: ……………………………………. …………………………………......
NHS Number: ………………………….. ……………………………………...
Phone number: Home………………… Mobile:......
Date of seizure: ………………….. Date of referral: …………………..
History of event: ………………………………………………………......
………………………………………………………………………………………………......
…………………………………………………………………………………………………..
PMH…………………………………………………………………………………………….
Current Medication: …………………………………………………………………………..
Driving Status: ………………………… Pt advised not to drive: Y / N
Referring Dr...... ……………………………………………………………………………….
If available please provide results for the following investigations:
ECG and FBC / U&E / LFT / GGT
Please email the form directly to (alternative ) or fax to 01792 703249 and send a copy to the patient’s GP
Please ensure that the patient is given the following advice and information:
Driving: Patients with a suspected epileptic seizure must stop driving immediately and inform the DVLA. Further information regarding driving will be provided following the assessment.
Lifestyle / Safety: Patients should be advised that whilst they are at risk of further events they should avoid bathing or swimming alone and try to avoid unnecessary risks such as climbing ladders.
We will aim to review urgently referred patients with a new onset suspected seizure within two weeks.
Information from witnesses is often crucial. Please could patients be advised to bring the witness or contact details of the witness to their clinic appointment.
Adult rapid access seizure clinic- GP referral form
Criteria for referral:
· Episode of transient loss of consciousness, suspected seizure
· Does not require hospital admission
· The patient is 16 years or older
· No previous diagnosis of epilepsy or prescribed anti-epilepsy medication
Name: ………………………………M/F Address: …………………………..
DOB: ……………………………………. …………………………………......
NHS Number: ………………………….. ……………………………………...
Phone number: Home………………… Mobile:......
Date of seizure: ………………….. Date of referral: …………………..
History of event: ………………………………………………………......
………………………………………………………………………………………………......
…………………………………………………………………………………………………..
PMH…………………………………………………………………………………………….
Current Medication: …………………………………………………………………………..
Driving Status: ………………………… Pt advised not to drive: Y / N
Referring Dr...... ……………………………………………………………………………….
If available please provide results for the following investigations:
ECG and FBC / U&E / LFT / GGT
Please either attach the form to the generic electronic template so that it can be sent via the electronic referral system (WCCG) or fax to 01792 703249
Please ensure that the patient is given the following advice and information:
Driving: Patients with a suspected epileptic seizure must stop driving immediately and inform the DVLA. Further information regarding driving will be provided following the assessment.
Lifestyle / Safety: Patients should be advised that whilst they are at risk of further events they should avoid bathing or swimming alone and try to avoid unnecessary risks such as climbing ladders.
We will aim to review urgently referred patients with a new onset suspected seizure within two weeks.
Information from witnesses is often crucial. Please could patients be advised to bring the witness or contact details of the witness to their clinic appointment.
For office use only: Please hand all referral forms to Tracey Prosser, Neurology, Morriston Hospital
Appendix 2: Paediatric rapid access seizure clinic- ED referral form
Criteria for referral:
· Episode of transient loss of consciousness, suspected seizure
· Does not require hospital admission
· The patient is less than 16 years
· No previous diagnosis of epilepsy or prescribed anti-epilepsy medication
Name: ………………………………M/F Address: …………………………..
DOB: ……………………………………. …………………………………......
NHS Number: ………………………….. ……………………………………...
Phone number: Home………………… Mobile:......
Names of carers: ……………………………………………………………………………..
Date of seizure: ………………….. Date of referral: …………………..
History of event: ………………………………………………………......
………………………………………………………………………………………………......
…………………………………………………………………………………………………..
PMH…………………………………………………………………………………………….
Current Medication: …………………………………………………………………………..
Referring Dr...... ……………………………………………………………………………….
Please email the referral directly to (alternative ) or fax to 01792 545744 and send a copy to the patient’s GP
Please ensure that the patient is given the following advice and information:
We will aim to review urgently referred patients with a new onset suspected seizure within two weeks.
Information from witnesses is often crucial. Please could patients be advised to bring the witness or contact details of the witness to their clinic appointment.
Please give a copy of the First Seizure leaflet which includes First Aid advice.
Paediatric Rapid Access Seizure Clinic- GP Referral Form
Criteria for referral:
· Episode of transient loss of consciousness, suspected seizure
· Does not require hospital admission
· The patient is less than 16 years
· No previous diagnosis of epilepsy or prescribed anti-epilepsy medication
Name: ………………………………M/F Address: …………………………..
DOB: ……………………………………. …………………………………......
NHS Number: ………………………….. ……………………………………...
Phone number: Home………………… Mobile:......
Names of carers: ……………………………………………………………………………..
Date of seizure: ………………….. Date of referral: …………………..
History of event: ………………………………………………………......
………………………………………………………………………………………………......
…………………………………………………………………………………………………..
PMH…………………………………………………………………………………………….
Current Medication: …………………………………………………………………………..
Referring Dr...... ……………………………………………………………………………….
Please either attach the form to the generic electronic template so that it can be sent via the electronic referral system (WCCG) or fax to 01792 545744 and send a copy to the patient’s GP and school nurse
Please ensure that the patient is given the following advice and information:
We will aim to review urgently referred patients with a new onset suspected seizure within two weeks.
Information from witnesses is often crucial. Please could patients be advised to bring the witness or contact details of the witness to their clinic appointment.
Please give a copy of the First Seizure leaflet which includes First Aid advice.
For office use only: Please hand all referral forms to Kelly Hapgood, Paediatrics, ADT Suite, Morriston Hospital
Appendix 3: ED First Fit Guidelines - adults
Mandatory Investigations
1. FBC / U&E / LFT / GGT/ blood glucose
2. Urine dipstick and pregnancy test
3. ECG
Immediate CT Head +/- admission if:
1. New focal neurological deficit
2. Altered mental state
3. Fever
4. Clear history of focal/partial onset
5. Persistent headache
6. Acute head trauma
7. Malignancy
8. Immunocompromised/HIV infection
9. Anticoagulation/bleeding disorder
Discharge with Neurology follow up <2/52 if:
1. Fully recovered
2. No focal neurological deficit
3. Initial investigations normal
Advise not to drive until seen in clinic and document in notes.
Emphasise the importance of bringing a witness to follow up appointment.