Use of emergency departments by known epileptic patients: An underestimated problem?

Non-1st seizure was less severe than 1st seizure with non-urgent level among suspected seizures transferred by ambulance

BACKGROUND

To prioritize emergency medical calls for ambulance transport for patients with suspected seizures, information about whether the event is their 1st or non-1st seizure is important. However, little is known about the difference between 1st and non-1st seizures in terms of severity. We hypothesized that patients transferred multiple times (≥2 times) would represent a milder scenario than patients on their first transfer. The purpose of this study was to compare patients with suspected seizures on 1st transfer by ambulance and patients who had been transferred ≥2 times.

METHODS

We statistically compared severity of suspected seizures between two groups of patients with suspected seizures transferred between December 2014 and November 2019 (before the coronavirus disease 2019 pandemic) to our facility by ambulance for either the first time (1st Group) or at least the second time (Non-1st Group). Severity categories were defined as: Level 1 = life-threatening; Level 2 = emergent, needing admission to the intensive care unit; Level 3 = urgent, needing admission to a hospital general ward; Level 4 = less urgent, needing intervention but not hospitalization; and Level 5 = non-urgent, not needing intervention.

RESULTS

Among 5996 patients with suspected seizures conveyed to the emergency department by ambulance a total of 14,263 times during the study period, 1222 times (8.6%) and 636 patients (11%) met the criteria. Severity grade of suspected seizures ranged from 1 to 5 (median, 4; interquartile range, 3-4) for the 1st Group and from 1 to 5 (median, 5; interquartile range, 4-5) for the Non-1st Group. Most severe grade ranged from 1 to 5 (median, 4; interquartile range, 4-5) for the Non-1st Group. Severity grade differed significantly between groups (p < 0.001, Mann-Whitney U-test). Uni- and multivariate logistic regression tests also suggested a significant difference (p < 0.001) in severity grades.

CONCLUSION

In direct comparisons, grade of suspected seizure severity was lower in the Non-1st Group than in the 1st Group.

Excessive hospitalization of patients with seizures in the Germany prehospital emergency system: a retrospective cohort study

Seizures are a common reason for calling emergency medical services. A lack of guidelines on prehospital treatment in Germany leads to high transportation rates and reduced confidence in decision making by professionals. Our aim was to investigate the reasons for hospitalization and evaluate their necessity. A retrospective analysis of all emergency medical services records in Munich, Germany was performed in order to examine the reasons for hospitalization of patients with seizures and to evaluate their trajectory following admission to a university hospital. 8882 records were analyzed with 415 records reporting seizures (4.9%). Primary endpoint was transportation to hospital. In 380 cases (92%) patients were transported, of which 177 patients (47%) had known epilepsy; 35 patients (8%) were left at scene. Older patients and patients with higher amounts of administered medication at the scene were hospitalized significantly more often (p = 0.032 and p = 0.004, respectively). Median hospital length of stay was 1 night [IQR 1–2]. In patients with out-of-hospital seizures, high hospital transportation rates were evident, most of which could be considered as not indicated. One possible reason is the lack of guidelines in Germany, which leads to uncertainty among medical staff. This results in distress for the patients, their caregivers and consequently high costs.

Patient views on use of emergency and alternative care services for adult epilepsy: A qualitative study

PURPOSE

Emergency Department (ED) visits are costly to the health service and alternative care pathways may address this whilst improving outcomes. We aimed to describe decision-making and preferences of people with epilepsy (PWE) during emergency service use, and views of ED alternatives, including use of an Urgent Treatment Centre and telephone-based support from an epilepsy nurse specialist.

METHODS

We conducted a community-based interview study in South East England, informed by a qualitative framework approach. 25 adults with epilepsy and 5 of their carers took part.

RESULTS

Participants' choice to attend ED generally corresponded with guidelines, including continuing seizures and injury. Nevertheless, over half reported unwanted or unnecessary ED attendance, mainly due to lack of access to individual patient history, a carer, or seizures occurring in a public place. Participants used proactive strategies to communicate their care needs to others, including 24 -h alarm devices and care plans. Some suggested preventative strategies including referral after ED. Participants highlighted the importance of ambulance staff in providing fast and efficient care that gives reassurance.

CONCLUSION

Improving communication and access to preventative, proactive services may facilitate better outcomes within existing care pathways. PWE felt ED alternatives were helpful in some circumstances, but Urgent Treatment Centres or epilepsy nurse specialists were not viewed as an ED replacement.

Short-term risk of relapse after a first unprovoked seizure in an adult population

OBJECTIVE

To evaluate the incidence of short-term recurrence (<1 month) after a first unprovoked seizure (FUS) and the associated risk factors.

METHODS

This is a prospective monocentric one-year observational study on all consecutive adult patients admitted to the Emergency Department (ED) and diagnosed as FUS. Patients underwent neurological consultation at one and three months after the FUS. Demographic information, clinical examination and seizure features, seizure recurrence at 1 and 3 months, electroencephalogram (EEG), brain imaging, precipitating factors, seizure type, and prescribed antiepileptic drugs (AED) were prospectively collected.

RESULTS

Among 140 patients diagnosed as FUS, 109 patients attended the neurological consultation at 1 month. FUS diagnosis was confirmed in 80/109 cases. Nine patients (11.2%) had seizure recurrence before the consultation at 1 month. Identified specific risk factors of short-term recurrence were focal seizure (P=0.015) and abnormal EEG in the first 48hours (P=0.048). In the group of patients followed for three months (38 patients), the risk of seizure relapse was 15.7%.

CONCLUSION

Most patients with FUS diagnosed in the ED did not present seizure recurrence within the first month, especially if no specific risk factors were present (focal seizure, abnormal EEG within first 48hours). The systematic use of prophylactic AED (benzodiazepines) is not recommended in the ED in the clinical setting of FUS. A specialized consultation within a one-month period is safe and adequate for FUS follow-up.

Exploring epilepsy attendance at the emergency department and interventions which may reduce unnecessary attendances: A scoping review

BACKGROUND

Repeat attendances to emergency departments for seizures, impacts on the individual and burdens health care systems. We conducted a review to identify implementable measures which improve the management of people with epilepsy reducing healthcare costs and their supportive evidence.

METHODS

A scoping review design using suitable search strategy as outlined by PRISMA-ScR was used to examine seven databases: MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, HMIC and BNI. A manual search of the COCHRANE database and citation searching was also conducted. A thematic analysis was conducted to explore the context and reasons of emergency department attendance for seizures, particularly repeat attendances and the strategies and measures deployed to reduce repeat attendances.

RESULTS

Twenty-nine reports were included, comprising of a systematic review, a randomised control study, a multi-method study, quantitative studies (n = 17), qualitative studies (n = 6), an audit, a survey and a quality improvement project. Thematic analysis identified four broad areas for reducing repeat attendances. These were developing care pathways, conducting care and treatment reviews, providing educational interventions and role of ambulance staff.

CONCLUSION

The findings indicate varied reasons for attendance at ED following seizure, including mental health and knowledge of seizure management and lack of education. Implementations of care pathways in ED have been found to reduce admission related costs.

The use of a dedicated neurological triage system improves process times and resource utilization: a prospective observational study from an interdisciplinary emergency department

Background

Patients with neurological symptoms have been contributing to the increasing rates of emergency department (ED) utilization in recent years. Existing triage systems represent neurological symptoms rather crudely, neglecting subtler but relevant aspects like temporal evolution or associated symptoms. A designated neurological triage system could positively impact patient safety by identifying patients with urgent need for medical attention and prevent inadequate utilization of ED and hospital resources.

Methods

We compared basic demographic information, chief complaint/presenting symptom, door-to-doctor time and length of stay (LOS) as well as utilization of ED resources of patients presenting with neurological symptoms or complaints during a one-month period before as well as after the introduction of the Heidelberg Neurological Triage System (HEINTS) in our interdisciplinary ED. In a second step, we compared diagnostic and treatment processes for both time periods according to assigned acuity.

Results

During the two assessment periods, 299 and 300 patients were evaluated by a neurologist, respectively. While demographic features were similar for both groups, overall LOS (p < 0.001) was significantly shorter, while CT (p = 0.023), laboratory examinations (p = 0.006), ECG (p = 0.011) and consultations (p = 0.004) were performed significantly less often when assessing with HEINTS. When considering acuity, an epileptic seizure was less frequently evaluated as acute with HEINTS than in the pre-HEINTS phase (p = 0.002), while vertigo patients were significantly more often rated as acute with HEINTS (p < 0.001). In all cases rated as acute, door-to-doctor-time (DDT) decreased from 41.0 min to 17.7 min (p < 0.001), and treatment duration decreased from 304.3 min to 149.4 min (p < 0.001) after introduction of HEINTS triage.

Conclusion

A dedicated triage system for patients with neurological complaints reduces DDT, LOS and ED resource utilization, thereby improving ED diagnostic and treatment processes.

Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review

Background

Uncompleted emergency department care and against-medical-advice discharge represent relevant medical problems with impact on patient safety and potential medicolegal and socioeconomic consequences. They may also indicate structural or procedural problems in the emergency department (ED) relating to patient management and flow. While patients with neurological complaints frequently leave the ED against medical advice or without being seen, no dedicated analysis of this group of patients aiming at the identification of characteristics associated with irregular ED discharge has been performed so far.

Methods

A chart review was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017 for neurological evaluation. Demographics, mode of presentation, process times, presenting symptoms and diagnosis were recorded. Patients leaving against medical advice after an informed consent discussion and signing of documentation (DAMA) or leaving prematurely without notifying ED staff (PL) were compared to the total of patients who were admitted or discharged (non-DAMA/PL).

Results

Of all patients presenting with neurological symptoms or complaints, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p < .001), and they were more frequently self-presenting (p < 0.001). Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the duration of door-to-doctor time.

Conclusions

Younger age, self-presenting mode of presentation and presentation with headache, seizures or sensory deficits are associated with premature leave or against-medical-advice discharge of patients with neurological complaints from the ED, and long waiting times were given as the major reason for leaving the ED. Increasing ED staff’s awareness of these factors and the optimization of pre-hospital assessment and demand management, thereby positively impacting on patient flow and ED process times, may help to prevent irregular discharges from the ED.

Healthcare resource utilization and costs before and after lacosamide initiation as adjunctive therapy among patients with epilepsy in the United States

OBJECTIVE

The objective of this study was to evaluate all-cause and epilepsy-specific healthcare resource utilization and costs following lacosamide (LCM) initiation as adjunctive therapy for the treatment of epilepsy.

METHODS

A noninterventional retrospective database analysis was conducted that examined patients diagnosed as having epilepsy who added LCM to existing antiepileptic drug (AED) therapy between 2009 and 2016 (the first LCM prescription was the index event). This study used a single-case design whereby patients served as their own controls. Patients were further required to have a minimum of 12 months of continuous eligibility before (preindex period) and after (postindex period) their index event. In the 12-month postindex period, the only allowed AED regimen change was the addition of LCM. Demographic and clinical characteristics were measured at index and during the preindex period, respectively. All-cause and epilepsy-specific healthcare resource utilization and costs were measured and compared in the pre- and postindex periods. Paired t- and McNemar's tests were conducted to assess the significant differences between pre- and postindex. Univariate analyses were used to analyze the impact of LCM on specific subpopulations.

RESULTS

The study sample comprised of 2171 patients: mean (standard deviation [SD]) age: 38.9 (19.3) years; 52.6% female. Just over half (56%) of these patients were on monotherapy before adding LCM. Prior to adding LCM, 28.8% of patients had an epilepsy-specific inpatient (IP) admission, and 35.7% of patients had an all-cause IP admission, compared with 18.2% and 26.1% of patients in the post-LCM period, respectively (both p < 0.0001). Likewise, 35.6% of patients had an epilepsy-specific emergency room (ER) visit, and 50.0% had an all-cause ER visit prior to adding LCM, compared with 23.8% and 42.1% in post-LCM, respectively (both p < 0.0001). After adding LCM, one-year mean [SD] epilepsy-specific IP admission costs decreased by 42.9% ($13,647 [$52,290] to $7788 [$32,321]), and all-cause IP admission costs decreased by 38.6% ($20,654 [$72,716] to $12,688 [$46,120]) (both p < 0.0001). One-year epilepsy-specific mean [SD] ER costs decreased by 35.2% ($691 [$1756] to $448 [$1909]; p < 0.0001), and all-cause ER cost decreased by 17.8% ($1217 [$3014] to $1000 [$2970]; p < 0.01).

CONCLUSIONS

Epilepsy-related IP hospitalizations and ER visits (indicators of seizures) were significantly reduced in patients with epilepsy 12 months after adding LCM as an adjunctive therapy to existing AED treatment in a real-world setting, leading to reduced healthcare resource utilization and epilepsy costs.

Perceptions of emergency care using a seizure care pathway for patients presenting to emergency departments in the North West of England following a seizure: a qualitative study

OBJECTIVES

To establish the appropriateness of a previously developed seizure care pathway by exploring to what extent patients valued the intervention and perceived it as being helpful or not.

DESIGN

Qualitative descriptive study, using semistructured, in-depth interviews and thematic template analysis, theoretically informed by critical realism.

SETTING

In North West England, a seizure care pathway has been developed in collaboration with a specialist neurology hospital to support clinical management of seizure patients on initial presentation to the emergency department (ED), as well as access to follow-up services on discharge, with the aim of improving patient experience. Three National Health Service (NHS) EDs and a specialist neurology hospital provided the setting for participant recruitment to this study.

PARTICIPANTS

181 patients fulfilled the inclusion criterion with 27 participants taking part following their experience of an ED attendance and outpatient follow-up appointment after a seizure.

RESULTS

Five main themes emerged from the data: decision to seek care, responsiveness of services, waiting and efficiency, information and support, and care continuity. Two integrative themes spanned the whole study: lived experience and communication. This paper reports on two of the main themes: care continuity, and waiting and efficiency. The average time between ED presentation and interview completion was 100 days.

CONCLUSIONS

Implementation of a care pathway is a complex intervention, requiring long-term follow-up to assess its integration into practice and effectiveness in service improvement. The seizure care pathway has the potential to enhance the care of seizure patients in the ED and at follow-up by improving continuity and management of care. The study demonstrates good aspects of the seizure care pathway as observed by patients and also recognises shortcomings within current service provision and questions what the NHS should and should not be delivering. Our study suggests various ways to enhance the pathway at service level to potentially drive improved patient experience.

First-aid management of tonic-clonic seizures among healthcare personnel: A survey by the Apulian section of the Italian League Against Epilepsy

INTRODUCTION

To evaluate the knowledge of healthcare workers about first-aid measures to be performed during and after a tonic-clonic seizure.

METHODS

One hundred and fifty-four healthcare workers (86 physicians) working at 8 tertiary hospitals in the Apulia region, Italy, responded to a questionnaire comprising of 28 questions based on available Italian and international recommendations about what to do during a tonic-clonic seizure.

RESULTS

One hundred and fifty-four healthcare workers completed and returned surveys with a response rate of 96.25%. There were 55 nurses (35.7%), 86 physicians (55.8%), and 13 healthcare workers with different roles (Electroencephalograph technicians, psychologists, social workers). Among physicians, there were 7 cardiologists, 3 surgeons, 12 infectious-disease specialists, 11 internal medicine specialists, 2 psychiatrists, 2 gynecologists, 27 specialists working in the emergency department, and 22 physicians with different specializations. Nearly 90% of the respondents identified head protection as important first aid, while 100% responded to not keep the legs elevated. To avoid tongue bite, both physicians and other healthcare workers would put something in the mouth (54.0%), like a Guedel cannula (71.0%) fingers (29.5%). Grabbing arms and legs, trying to stop the seizure, would be potentially performed by 11.6% of our sample. Physicians would administer a benzodiazepine during the seizure (65.7%) and during the postictal phase (29.2%), even if the patient is known to have epilepsy (23.7%), and in this case, 11.3% of respondents would administer the usual antiepileptic medications. More than half of respondents would call the emergency telephone number, because of necessary hospitalization in case of tonic-clonic seizure, even if it is experienced by a patient known to have epilepsy.

CONCLUSION

Our survey suggests the need for epilepsy educational programs on first-aid management of seizures among healthcare workers.

Qualitative study of paramedics' experiences of managing seizures: a national perspective from England

OBJECTIVES

The UK ambulance service is expected to now manage more patients in the community and avoid unnecessary transportations to hospital emergency departments (ED). Most people it attends who have experienced seizures have established epilepsy, have experienced uncomplicated seizures and so do not require the full facilities of an ED. Despite this, most are transported there. To understand why, we explored paramedics' experiences of managing seizures.

DESIGN AND SETTING

Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed.

PARTICIPANTS

A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics.

RESULTS

Participants' confirmed how most seizure patients attended to do not clinically require an ED. They explained, however, that a number of factors influence their care decisions and create a momentum for these patients to still be taken. Of particular importance was the lack of access paramedics have to background medical information on patients. This, and the limited seizure training paramedics receive, meant paramedics often cannot interpret with confidence the normality of a seizure presentation and so transport patients out of precaution. The restricted time paramedics are expected to spend 'on scene' due to the way the ambulance services' performance is measured and that are few alternative care pathways which can be used for seizure patients also made conveyance likely.

CONCLUSIONS

Paramedics are working within a system that does not currently facilitate non-conveyance of seizure patients. Organisational, structural, professional and educational factors impact care decisions and means transportation to ED remains the default option. Improving paramedics access to medical histories, their seizure management training and developing performance measures for the service that incentivise care that is cost-effective for all of the health service might reduce unnecessary conveyances to ED.