Epilepsy is the most common serious neurological disorder of young people affecting nearly 3.4 million individuals in Europe [
Despite the heavy burden of seizures in the ED, international studies suggest that the majority of patients are referred unnecessarily for admission and that the acute treatment of seizures is often ineffective indicating that seizure admissions are a cause of unnecessary medical intervention, delayed diagnosis, and prolonged length of stay [
Beginning in 2006 we first sought to determine the impact of emergency seizure admissions on the resources of a large Irish teaching hospital. On the basis of two baseline audits we identified a number of areas where we could improve the quality of service to patients with seizures by the employment of an evidence-based seizure care pathway in the emergency department (ED) and acute medical admissions unit (AMAU). This is a report of preliminary quality and safety metrics accrued by this intervention over a 12-month period (November 2008-2009).
The study consisted of three parts: Retrospective audit of admissions with seizures through the emergency department in 2004. Prospective audit of admissions with seizures through the emergency department in August 2006. Measurement of quality and safety metrics after the implementation of an evidence-based seizure care pathway from November 2008 to November 2009.
The first study group was restricted to in-patients discharged in 2004 with a diagnosis of a seizure or convulsion. These patients were identified through the Hospital In-Patient Enquiry (HIPE) system (a national coding system for hospital discharges in Ireland), [
The second study group represented all patients who attended the ED with an event that was deemed likely to have been a seizure or its aftermath over one calendar month in 2006. A total of 102 patients were considered eligible for inclusion. Patients who presented with a complaint of seizure, weakness, confusion, head injury, dizziness, and collapse of unknown cause were examined for possible inclusion in the study. In a similar vein to part 1 of the study, attention was paid to investigations, diagnosis, referral, and follow-up in all patients.
After the baseline audits, a seizure care pathway was designed and implemented by the neurology service with the cooperation of the ED staff. The pathway required early rapid access ambulatory follow-up for patients fit for discharge from the ED. A rapid access clinic (RAC) was established and run by an existing epilepsy nurse specialist (ENS). In addition to patients discharged from wards and the ED, this clinic also reviewed new referrals from GPs and patients with an established diagnosis of epilepsy who had exacerbations of their illness, all of which were designed to avoid ED referrals. Education sessions were provided by the ENS who also provided a phone help-line and e-mail service to facilitate follow-up care. The clinic was overseen by a neurologist. Patients presenting to the ED or admitted to the AMAU overnight with seizures were seen by the seizure service fellow. Referrals were made through an Electronic Patient Record (EPR) consultation system.
Patients were managed according to a locally designed, evidence-based, Seizure Care Pathway (Figure Admission, discharge and follow-up. Emergency treatment in the ED or AMAU. A decision analysis for diagnostic tests. Referral process for Nurse specialist education and self-management strategies.
The Seizure Care Pathway used in the Intervention Study from November 2008.
The pathway was designed with reference to published international guidelines of care (Scottish Intercollegiate Guideline Network (SIGN) 2003 (8) and National Institute of Clinical Excellence (NICE) 2005 (9)). All patients seen by the seizure service were provided with printed cards with full details for phone and e-mail contact.
Statistical analysis was carried out on SPSS Version 18 (SPSS Inc., Chicago, IL). Length of stay and time to CT, MRI and EEG were analysed using Kruskal Wallis test for nonparametric data. The rate of representation was analysed using Pearson Chi-square test. Times to follow-up were analysed using the Mann-Whitney
During 2004, HIPE data identified 341 admissions with a specific diagnosis of epilepsy or seizure out of a total of 11,721 admissions from all causes through the ED. The median length of stay was 4 days.
In the 50 charts randomly selected out of this group, 34% of patients had a previously documented diagnosis of epilepsy at presentation. Investigations performed included CT brain (84%), MRI brain (28%), and EEG (56%). Median delay to CT, MRI, and EEG were 2 days, 5 days, and 5 days, respectively. Ambulatory follow-up was evenly divided between Neurology (28%), General Medicine (28%), and General Practitioner (20%), with a further 24% having no follow-up whatsoever. 23/50 patients (46%) represented to the emergency department with further seizures over the next 12 months.
Using our criteria for “Necessity of Admission,” we concluded that 36% could have been discharged earlier or from the ED, had appropriate investigations and neurological opinion been available in a timely manner. Of the 341 patients with a diagnosis of epilepsy, 10 died over the subsequent year but only one of those who presented with status epilepticus died as a direct result of their epilepsy.
20 (19%) of the 102 patients included in the study had a previously established diagnosis of epilepsy. 34 (33%) patients were admitted though the ED. Median length of stay of those admitted was 5 days. Of the special investigations required for epilepsy, CT Brain was the only one conducted on the day of admission and in only 5.8% of cases. Neither MRI nor EEG’s were performed on any patient on the day of presentation. Ultimately of the 34 admitted, 14 (41%) had an EEG, 21 (61%) patients had a CT brain, and 4 (12%) had an MRI Brain. Median delay for EEG was 2 days; CT brain was 1 day, and MRI was 2.5 days. No data was collected on mortality or follow-up as it was designed primarily to gather data on patients presenting to the ED.
During 2009, there were 276 admissions with a primary diagnosis of epilepsy out of 12, 607 admissions from all causes through the ED. 350 patients who presented to ED between November 2008 and November 2009 with seizures and other forms of collapse were referred to the seizure team for assessment and had the seizure care pathway applied. 97 patients had an established history of either generalised or focal epilepsy and 72 patients had epilepsy associated with significant medical and surgical comorbidities. 34 patients were referred with undefined collapse, 12 patients were referred with confusion, and 4 patients with myoclonic jerks. Collapses, nonepileptic seizures and confusion accounted for 57 referrals (16.2%). Table
List of admitting diagnosis.
Underlying diagnosis of study cohort | Numbers |
---|---|
Preexisting diagnosis of primary generalised epilepsy | 37 |
Preexisting diagnosis of localisation related epilepsy | 60 |
Generalised status epilepticus | 7 |
Nonepileptic seizures | 11 |
Collapses | 34 |
Antiepileptic medication-related toxicity | 3 |
Significant past medical history of head injury | 6 |
Known primary CNS tumours | 8 |
Known CNS metastasis | 6 |
History of stroke/TIA | 8 |
Stroke presenting as seizures | 2 |
Known history of learning disability | 5 |
Dementia | 5 |
HIV positive | 2 |
Hepatitis B/C positive | 10 |
Schizophrenia | 1 |
Hyponatraemia | 11 |
Sepsis with symptomatic seizure | 1 |
Sepsis with rigors misidentified and referred as seizure | 3 |
Post-operative seizures | 3 |
Seizure after significant physical trauma | 1 |
111 (31%) patients were discharged directly from the ED. 30 (8.5%) patients stayed more than 30 days. The median length of stay was 2 days.
Of the 181 EEGs requested during the intervention study period, 99 (55%) were done on the same day. 66 (36%) were done within 1 to 3 days, and 16 (9%) were done as outpatients within 4 weeks. The median delay for EEG in the intervention study was zero days. 150 patients had CT Brain requested and 140 (93%) were performed on the same day and median delay for CT brain was again zero days. In 2008-2009, 68 (19%) of the total cohort of 350, had MR imaging of the brain requested. Same day MR brain acquisition however went up from 0% in 2004 to 7.2% in 2008-2009 and another 8.8% cases were done within 1 to 3 days. The median delay for MRI brain was 8 days in 2008-2009. Of the 57 patients with nonepileptic collapse, 12 had an EEG, 18 patients had CT brain and only one patient had an MRI brain performed.
216/350 patients (61.7%) were seen in follow-up clinics. 110 patients (31.4%) were seen in the Rapid Access Clinic (RAC). The median follow-up time to review in the RAC was 4 weeks. 64 patients (18%) were seen in the subspecialty epilepsy clinic and median follow-up time for this more stable group was 8 weeks. 18 patients (5.1%) were followed up by other services. 6 patients (1.71%) were followed up in other hospitals 31 (8.9%) of the total study group were readmitted in the 12-month follow-up period.
Of the patients seen during the study period, 19 (5.4%) patients died during the subsequent 12-month follow-up. Only 5 of those died from neurological causes. The remainder died of a combination of respiratory, cardiac, and oncological causes. The neurological causes of death were herpes encephalitis, obstructive hydrocephalus, nonconvulsive status epilepticus and subdural haematoma. Three patients died of direct seizure-related causes, two with nonconvulsive status epilepticus, and one with convulsive status epilepticus. During the intervention study period no patient who was discharged from the ED or within 2 days of admission died.
The number of admissions with epilepsy or seizure dropped significantly from 341 out of 11,721 (2.9%) in 2004 to 276 out of 12, 607 (2.2%) in 2009 (
There was a significant reduction in median length of stay between the first 2 audits and the intervention study (
Median length of stay is shown in days for each of the study periods in Figure
There was a significant improvement in time to diagnostic investigations such as CT brain, MRI brain, and electroencephalography between the first two audits and the intervention study (
The median length of time to CT brain, EEG and MRI brain for each of the study periods.
There was a significant reduction in follow-up times from a median of 16 weeks to 5 weeks (
The median time to follow-up in weeks for the baseline audit in 2004 and the intervention study in 2008-2009.
There was a significant reduction in readmission rates from 45.1% to 8.9% (
The rate of representations of patients with seizures to the Emergency Department in 2004 and during the intervention study in 2008-2009.
The use of care pathways in modern healthcare delivery has been somewhat controversial since the expected gains are not always forthcoming. For instance a Cochrane review of the implementation of a care pathway in stroke rehabilitation did not endorse any benefit to patient care [
The aim of this study was to demonstrate improvements in for patients presenting to the ED with seizures and related disorders, without compromising safety by the use of an evidence-based seizure care pathway. The main quality indicators measured were requirement for admission, median length of stay, time to diagnostic tests, specialist follow-up, readmission rates, and mortality.
The main findings of the study are that through the utilization of the Seizure Care Pathway the ED and AMAU can reduce unnecessary admissions and safely discharge patients for early follow-up, which has a very significant impact on reducing representation rates. Timely decision support has the effect of significantly reducing time to diagnostic tests, particularly EEG, and thus reducing median length of stay by up to 3 days. All of these outcomes were significant statistically and support the use of care pathways for patients presenting to the ED with seizures without any increase in mortality. Below we examine each of these benefits.
It has been suggested that admission of seizure patients is only warranted in patients who are at high risk of further events, remain drowsy or comatose following a period in the ED, or in whom the neurological exam reveals signs indicative of an underlying lesion or treatable infective cause. However, international studies suggest that the majority of patients are referred unnecessarily to the in-house medical or neurological services for admission [
Comparison of HIPE data between 2004 with that of 2009 following implementation of the seizure care pathway shows a reduction in the number of admissions with a specific diagnosis of epilepsy from 2.9% (341) of total hospital admissions to 2.2% (276). This is despite an increase in overall admission rates from ED of 7.56% from 11,721 in 2004 to 12,607 in 2009. Had admissions continued at the rate of 2.9% with no seizure care pathway in place, it would have resulted in 365 epilepsy-related admissions in 2009, suggesting that 89 epilepsy specific admissions were avoided due to implementation of the seizure care pathway in 2008 to 2009. If we consider the median LOS to be 4 days (without the seizure care pathway being applied) this would have resulted in 356 bed days saved. Combining this figure with the 478 bed days saved by an overall median reduction in LOS of 2 days, a total of 834 is the projected bed days saved in one 12-month period as a direct result of the implementation of the seizure care pathway.
The reduction in median length of stay from 4 days in 2004 and 5 days in 2006 to 2 days during the intervention study in 2008-2009 was made possible by an emphasis upon early safe discharge in the pathway with an eye to reduce bed occupancy days. Establishment of a separate rapid access follow-up clinic made routine and even unscheduled early follow-up possible, which increased the safety and ease of early discharge. Reductions in length of stay secondary to implementation of care pathways have been reported in other areas of heath care, but not in the case of patients with seizures [
Of the discharged patients, 91.1% were not readmitted with epilepsy-related causes. The readmission rates show a significant drop from 47% to 8.9% between 2004 and 2008-2009. The reasons for such a drop are unclear. It is possible that some unobserved bias meant that patients more likely to return were seen in the 2004 audit. It may be due to a combination of more timely and effective inpatient management including the delivery of inpatient ENS education, the provision of phone and e-mail advice services, the use of rapid access to ambulatory clinics for exacerbations of existing epilepsy, and improved, timely communication with primary care teams. The reduction of median follow-up time from 16 weeks during 2004 to 5 weeks in 2008-09 may also have helped in reducing re-admissions to the ED.
In relation to the overall safety of the seizure service with its emphasis on reducing admissions and length of stay, we found that only three of the 19 deaths in the study group were directly attributable to epilepsy. In 2004, only one death was attributable to epilepsy. While there is a slight increase in epilepsy-related deaths, there was no excess mortality in any patients discharged from the ED or within the 2-day median length of stay window.
Accurate diagnosis and classification of seizure type are essential to the provision of quality patient care and good control. EEG is described as an important aid in the evaluation of seizure patients [
Neuroimaging is essential to identify structural lesions, which may result in the development of a seizure disorder. Jackson et al. [
As outlined by the SIGN [
Retrospective chart reviews, which formed the basis of initial baseline data, are hazardous for deciding on service provision due to the unreliability and potential bias in the data. Furthermore, the initial analysis was on a relatively small number of charts. In this study we complimented the retrospective audit with a short prospective audit, which validated some of the retrospective audit and independently verified characteristics of patients admitted with epilepsy and their course in hospital. The intervention study was large enough to draw conclusions but its comparison to the two prior audits must be done with caution as the patient characteristics may have been biased in the smaller studies. This was exemplified by the significant differences in readmission rates between the two audits and the intervention study. While some of the difference were undoubtedly due to service improvements, the scale of difference suggested a possible bias in patient characteristics.
Finally, for system-wide change the decisions that contributed to the improved quality metrics would have ideally been made by ED and acute medical staff and specialist nurses applying the principles in the seizure care pathway. In this study the pathway was implemented by a specialist service and thus the generalizability of the results in unclear. However, the lack of widespread use of pathways for seizure presentations requited that a proof of principle study was required. Future study should now focus on the use of an integrated care pathway (ICP) without resource necessarily to a specialist at the ED/AMAU interface.
It appears that a large proportion of seizure-related presentations are referred to the in-house medical or neurological teams for admission, due in large part to the lack of access to appropriate algorithms for admission and decision support for early treatment and diagnostic investigation and the difficulty in obtaining outpatient investigations and specialist epilepsy follow-up in a reasonable length of time. This study conducted over a 12 month period using baseline data collected between 2004 and 2006 shows that using an evidence-based care pathway with early specialist advice and follow-up, along with directed patients education and a range of communication tools to aid in self-management such as telephone and e-mail advice, can contribute significantly to quality and value improvements in epilepsy care without compromising safety. We recommend further study of this programme and we have embedded a continuous improvement cycle into prospective audit.