GROUP MEMBERS:

DR GAIL REID DM (YEAR 3.5)

DR OLSHEATH BOWEN DM (YEAR 1.5)

DR PETER ANDRE SOLTAU (YEAR 2.5)

OBJECTIVES

• “Get a copy of the UHWI ED seizure protocol”• “Will need to evaluate a minimum of 60 patients”

• ”If the patients met the criteria for CT or not as per UHWI protocol, then if CT was done or not.”  

FIRST TIME SEIZURES• The physician must seek to establish that the

attack was truly a seizure

• If there is any persistent alteration of mental status or neurological deficit a CT brain should be done in the emergency department and reviewed

• CT Scan may be done as outpatient if patient returns to normal neurological status

Prepared by Dr Eric Williams

FIRST TIME SEIZURES

• Generally speaking patients with a first time seizure may be referred for follow up with EEG and CT brain to the Neurology Clinic at UHWI or a private neurologist depending on patient preference.

• There is no need to start antiepileptic drugs in these patients

• These patients must be reviewed within 2 weeks of discharge from the ED (in order to expedite the management as a result of an abnormal investigation) Prepared by Dr Eric Williams

FIRST TIME SEIZURES• Most patients with a simple febrile seizure who recover fully and

have a focus for their fever e.g. otitis media, UTI, simple LRTI should receive antipyretic measures and have fever reduced in the ED

• They do not require antiepileptic drugs

• The specific infection should be treated. These patients should be followed up by the paediatrician in Room 2 or their private paediatrician within 24--‐48 hours. They do not usually require a CT scan

Paed Emerg Management guidelines by Prof Gray UWI

REASONS FOR TOPIC SELECTION

• Patient Safety

• Cost (CT Brain = Ja $40,000)

• Litigation (missing serious pathology)

AIMS

• To document % compliance of the management of first time seizures in the ED as per clinical protocols for the Emergency Department

• To improve compliance of the management of first time seizures in the

MATERIALS & METHODS

• This clinical policy audit was directed by the Emergency Medicine Division of the UHWI

• It was conducted at the Emergency Department (ED) of a 500-bed university affiliated, tertiary care hospital in Mona, Kingston, Jamaica

• We reviewed medical records of all patients who had been diagnosed with first time seizure/ ? First time seizure from October 1, 2012 through October 1, 2013

STUDY SUBJECTS

• Patients were identified via a manual search of UHWI Accident &Emergency (A&E) log books, a discharge column diagnosis for “seizure”, specifically “first time seizure” triggered a docket number collection and docket trace via docket library through the medical records department of the UHWI.

DATA COLLECTION

Data abstracted from the medical records included:

• Docket/file #

• Gender

• Age

• Past medical history

• Duration of seizure

• Febrile seizure

• Focal seizure

• Status epilepticus

• Persistent alteration of mental status

• Neurological deficit

• CT scan done in Emergency Department

• CT scan ordered as outpatient

• If follow up was arranged for CT review.

DATA COLLECTION• The data were collected on a pre-designed data

abstraction form and then were entered into a standard spreadsheet (Excel 2010, version 14.0.7106.5003; Microsoft Corporation, Redmond, WA).

RESULTS• During the period of October 1, 2012 through October 1,

2013, 133 cases were identified with a possible diagnosis of first time seizure from the A&E log books

• A total of 133 dockets were requested from the docket office/library, however only 83 (62%) were located and upon in depth review by three investigators to determine the patients who met the criteria this resulted in 44 (33%) patients with a diagnosis of first time seizure

GENDER & AGE• 27 Females : 16 Males

• Age range 1 – 92 years old

AGE• Total of 16 paediatric patients

• 11 % of patients were age 1 or below• 25 % of patients were age 3 or below• 31 % of patients were age 5 or below

• No patient below age 2 had any medical illnesses while all patients (6) defined as elderly (age 60-65 and above) had at least 1 medical illness, most commonly hypertension

DURATION OF SEIZURE

• In 18 patients (40% of cases) the duration was unable to be assessed due to poor documentation

• 15 patients – lasted less than 5 minutes

• 19 Patients – lasted 5 minutes or less

• 5 Patients – lasted 10 minutes or more

SEIZURE PATTERN

• 7 patients were found to have status epileptics

• 4/7 patients had CT in the ED• 5 patients had persistence of mental status

changes

• 4/5 with altered mental status had CT done in the ED

• 4 had documented neurological deficit

• All 4 had CT in the ED• 4 patients had focal seizures

• All 4 had CT in the ED

WAS CT INDICATED IN THE ED ?• 20 patients – CT indicated in the ED

• In 2 of these patients CT was not done in the ED

• 21 patients – CT not indicated in ED

• 2 of these patients had CT done in the ED

• 3 patients – Unsure if CT done in ED

PROTOCOL FOLLOWED FOR CT IN ED• In 35 cases the protocol was followed

• In 4 cases the protocol was not followed

• In 5 cases it was unclear

35

44- 5100 89.7%

IF CT WAS NOT INDICATED, WAS PROTOCOL FOLLOWED FOR FOLLOW UP?

• In 5 cases protocol was not applicable e.g. patients admitted, CT already done

• In 4 cases – unsure

• Did not identify any case or patient in which follow up protocol was followed

• In one case, the protocol was followed however the patient required CT in ED and not as outpatient

FOLLOW UP FOR REVIEW

• 7 patients were to be followed up for review, however there is no documentation as to CT being ordered as outpatient

LIMITATIONS

Legibility of log book entries

Inability to get dockets from docket library

Missing notes from docket :Inability to locate notes of seizure presentation when docket retrieved

Documentation : Insufficient note taking by physicians/ medical staff : poor history taking

Any patient who was not recorded in the log book would have been excluded (?#)

RECOMMENDATIONS

A copy of clinical protocol book to be placed in A&E for quick referencing

Encourage staff to keep up to date with clinical policy book, e.g. in academic meetings/ death conferences

Addition of electronic records

Encourage legibility of log book entries

CONCLUSION

• High rate of compliance with protocol for CT scans in the ED for patients with first time seizures

• Poor documentation by physicians : seizure duration, follow up, CT as outpatient

• Poor compliance with follow up protocol

• Need for continued medical education

CT ordered as outpatient?

Follow up for CT review ?

Protocol followed for follow up

CT indicated in ED?

CT done in ED ?Protocol followed

no yes N/A yes yes yesno no no no no yesyes no no yes unavailable ?no no no no no yesno yes N/A yes yes yesno no no no no yesno yes N/A yes yes yesno no no no no yesno yes N/A yes yes yesno no N/A yes yes yesno yes N/A yes yes yesno yes N/A yes yes yesno no no no no yesno no no yes no nono yes no no no yesn/a n/a ? yes ? ?no no no no no yesyes neuro clinic yes Yes no no

n/apatient transferred KPH 

N/A ?Requested, no documentation

?

Admitted / n/a n/a N/A ? no ?n/a N/A N/A Yes yes yes? ? ? ? no ?n/a n/a N/A No yes noadmitted pedi n/a N/A No no yesn/a n/a N/A Yes yes yesno no no No no yesn/a n/a N/A Yes yes yes? ? no No no yesreferred pedi n/a N/A No no yes

N/A No no yes

? ? ? No no yesno n no No no yesno n N/A yes yes yesno n N/A Yes yes yesno n N/A yes yes yesno n N/A yes yes yesno n N/A yes yes yes? ? ? no no yesno n no no no yesno n N/A no yes no? ? ? no no yes? ? ? no no yesno n no no no yesno n N/A yes yes yes

admitted pedi, complex partial